
LECTURES 



ON THE 



ERUPTIYE EEYERS: 



AS NOW IN THE COURSE OF DELIVERY AT 

' ST. THOMAS'S HOSPITAL, IN LONDON. 

/by . 

GEORGE GREGORY, M.D., 

FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS OF LONDON ; PHYSICIAN TO THE 

SMALL POX AND VACCINATION HOSPITAL AT HIGHGATE ; CORRESPONDING 

MEMBER OF THE NATIONAL INSTITUTE OF WASHINGTON, ETC. 



FIKST AMERICAN EDITION. 

WITH NUMEROUS ADDITIONS AND AMENDMENTS BY THE AUTHOR, COMPRISING 
HIS LATEST VIEWS. 

WITH NOTES AND AN APPENDIX, 

EMBODYING THE MOST RECENT OPINIONS ON EXANTHEMATIC PATHOLOGY ; AND 
ALSO STATISTICAL TABLES, AND COLORED PLATES. 



H. D. BULKLEY, M.D., 



PHYSICIAN OF THE NEW YORK HOSPITAL ; FELLOW OF THE NEW YORK COLLEGE 
OF PHYSICIANS AND SURGEONS, ETC., ETC. 



NEW YORK: 

S. S. & W. WOOD, PUBLISHERS, 
261 PEARL STREET. 



MDCCCLI. 



Entered according to Act of Congress in the year 1851, by 

S. S. & W. WOOD, 

in the Clerk's Office of the District Court for the Southern District of New York. 



ROBERT CRAIGHEAD, PRINTER, 
112 FULTON STREET, 



5 ? 



«3 



SIR CHARLES MANSFIELD CLARKE, BART. 

M.D., F.R.S. 



My dear Sir Charles, 

The days are gone by when dedications could be relied on 
as passports to public favor ; but I hope it will never be out of fashion to 
make a public profession of gratitude, esteem, and respect. I am proud to 
acknowledge myself as your pupil, and to avow that from you I learned, 
not only the science of physic, but the art of lecturing. 

The position which you occupy in society sufficiently attests your skill 
and acquirements ; but the esteem and regard of your brethren, which no 
one ever enjoyed in a higher degree, have been earned by still higher 
qualities of mind, by great urbanity, and an untiring readiness to promote 
the professional advancement of your juniors. 

I have yet another reason for prefixing your name to these pages. They 
treat of diseases which occur for the most part in that early period of 
human life, to the management of which your thoughts have been in a 
great degree directed. In submitting my ideas to your judgment, I feel that 
I am subjecting them to their severest ordeal. 

I am, my dear Sir Charles, 

Ever very faithfully yours, 

GEORGE GREGORY, 

31 Weymouth Street,. 
March 16, 1843. 



PREFACE 



The following short course of Lectures on the Eruptive 
Fevers was delivered in the Theatre of St. Thomas's Hospi- 
tal, between the 18th January and the 8th February, 1843, 
It was thought that the experience which twenty years of 
official connexion with the Small Pox and Vaccination 
Hospital had given to the author might contribute something 
towards that extended and improved system of medical 
education now pursued in that school. 

The Lectures are published in the same form as that in 
which they were delivered, with the exception of certain 
portions necessarily omitted in the oral delivery, in order 
that what was calculated for thirteen lectures might be com- 
pressed into eleven. 

The author is very conscious of one imperfection of the 
present volume. He is fully aware that the conversational 
tone adapted for the lecture-room does not suit the closet so 
well as the gravity of a didactic style ; and that many, who 
might be inclined to look with favor on the matter, may 
very reasonably object to the manner. 

The author would anticipate one other criticism. Those 
who are in possession of the " Library of Practical Medi- 
cine " will at once perceive that a chapter in the first volume 
of that work has here been laid heavily under contribution ; 
but as, in so doing, the author only borrows from himself on 
points where later experience has suggested no improvement, 
he trusts to obtain the kind indulgence of the reader. Should 



VI PREFACE. 

he chance to be of the number of those who from age or posi- 
tion in the profession are more fitted to give than to receive 
instruction, the author ventures to hint that these Lectures 
were written for the use of pupils. His sole reason for com- 
mitting them to the press is, a hope that it may prove useful 
to present a picture of modern as contrasted with ancient 
pathology, and to amalgamate with established theory and 
practice the searching but faithful result of statistical science. 

G, G. 

31 Weymouth Street, Portland Place, 
March 17th, 1843. 



PREFACE OF THE EDITOR 



The Lectures on the Eruptive Fevers by Dr. Gregory, of 
which we have the pleasure of presenting a reprint to our 
American brethren, were first delivered and published in 
London, in 1843, and have been annually repeated at St. 
Thomas's Hospital since that time. 

The importance of the subjects of which they treat, and 
the high standing of their author on both sides of the Atlantic, 
a standing which gives his opinion the greatest weight in 
matters relating to the febrile exanthemata, led to the belief 
that the re-publication of them would be rendering an accept- 
able service to the profession in this country. 

The plan was communicated to the author, who at once 
expressed his full approbation of it, and has subsequently 
evinced a warm interest in its success, by sending to the 
editor, at intervals, numerous additions and emendations, 
comprising his more recent statistical investigations, and 
giving his opinions on these| subjects to the present time. 
These additions and emendations are incorporated in the 
present edition of the work, and add, it is thought, very much 
to its value. 

The contributions of the editor are intended to combine 
the results of his own experience, and such selections from 
authors of approved authority as was thought would supply 
any omissions, or give increased interest to the original 
work. 

In the Appendix are given tables, containing such statistics 



of the four epidemic diseases, small pox, measles, scarlet 
fever, and hooping cough, in the cities of New York, Phila- 
delphia, Boston, Providence (R. I.), Lowell (Mass.), Baltimore, 
and Charleston (S. C), and in the State of Massachusetts, as 
could be obtained ; and also some more extended remarks on 
various topics treated of by the author, which the editor 
considered more appropriate to this portion of the work. 

To enhance still further, as was hoped, the interest and 
value of the work, plates of the vaccine disease as it appears 
in the cow and on the hands of those inoculated from this 
source, copied from the beautiful and faithful illustrations of 
this affection by Mr. Ceely, of Aylesbury (Engl.), in his work 
on the variolae vaccinae, have been annexed. 

The editor is happy to acknowledge the aid which he has 
received in constructing his statistical tables from the valu- 
able labors of Dr. Emerson, of Philadelphia, Dr. Joynes, of 
Baltimore, and Dr. Parsons, of Providence. The other and 
principal items in the tables have been derived from public 

documents. 

H. D. B. 

43 Bleecher Street, 
March 6, 1851. 



CONTENTS 



LECTURE I— CHARACTER AND AFFINITIES OF THE ERUP- 
TIVE FEVERS, 1 

Mutual Relation of Diseases, 2 

Varieties of Cutaneous Disease, ........ 4 

Exanthematie Mortality, ......... 5 

General Character of the Exanthemata, 10 

Exanthematous Fever, 11 

Specific Eruption, 15 

Alleged Identity of the Exanthematie Poisons, 16 

Law of Suspension, .......... 18 

Affection of Mucous Surfaces accompanying Exanthema, . . .18 

Structures Secondarily Implicated 20 

LECTURE II.— CHARACTER AND MANAGEMENT GF THE 

ERUPTIVE FEVERS, 22 

Law of Universal Susceptibility, 22 

Law of Non-Recurrence, 23 

Contagious Origin, 25 

Modes of Miasmatic Access, ........ 26 

Theory of Zymosis, 29 

Quarantine, . . . . . . . ... . . .30 

Epidemic Diffusion, 31 

Management of the Exanthemata, 36 

Influence of Medicine over the course of Eruptive Fever. . . .39 

LECTURE III.— EARLY HISTORY AND PHENOMENA OF SMALL 

POX, 41 

Pestilence of Procopius, ......... 42 

First appearance of Small Pox in England, 43 

Introduction and Progress of Inoculation, ...... 46 

Variolous Incubation, 49 

Initiatory Fever, 50 

Characters of Variolous Eruption, 53 

Maturative Stage, 56 

Implication of the Mucous Membranes, 57 

Implication of the'Cellular Membrane, 59 

Secondary Fever, and its Consequences, 59 

Implication of the Nervous System, 61 

Petechial Small Pox, 62 

Small Pox with Gangrene, ......... 63 

Variolous Ophthalmia, ......... 64 

Implication of Internal Organs, 65 

Appearances on Dissection, ......... 66 



X CONTENTS. 

Page 

LECTURE IV.— STATISTICS AND PATHOLOGY OF SMALL 

POX, 68 

Diagnosis of Small Pox, 68 

Statistics of Small Pox, . . .70 

Proportion of Mild to Severe and Fatal Cases, 74 

Periods of the Disease at which Death occurs, 76 

Direct Causes of Death in Small Pox, 76 

Pathology of Small Pox, 77 

Question of Spontaneous Origin, 79 

Circumstances that determine severity, 81 

Miasmatic Origin, 83 

Epidemic Diffusion of Small Pox 84 

Susceptibility of Small Pox, . 86 

Recurrent or Secondary Small Pox, . . . . . .88 

Communication of Small Pox to the Foetus in Utero 91 

LECTURE V.— MANAGEMENT OF SMALL POX 93 

Early opinions concerning the Management of Small Pox, . . .94 

Sources of danger in Small Pox, 95 

Treatment during the Initiatory Fever, 97 

" during the Maturative Stage, 100 

" of the Mucous Complication, 102 

" Local, of the Pustules, 102 

" in the Secondary Fever, 105 

of the Sequelae of Small Pox, 106 

" External, during Secondary Fever, 107 

Inoculation of Small Pox, 108 

Results of Inoculation, . . . . , . . . .110 
Abolition of Inoculation, 113 

LECTURE VI. RUBEOLA, OR MEASLES 114 

Characters of Rubeola, 114 

Early History of Rubeola, 115 

Incubative Stage, 117 

Characters of the Initiatory Fever, 118 

Rubeola sine Catarrho, 121 

Maturation of Measles, 123 

Rubeolous Pneumonia, 126 

Other Sequelae of Measles, 128 

Malignant Measles, 129 

Cancrum Oris, 131 

Diagnosis, 134 

Recurrent Measles, . . . 137 

Inoculation of Measles, 138 

Statistics of Measles, . 140 

Treatment of Measles, 142 

LECTURE VIL— HISTORY AND PHENOMENA OF SCARLET 

FEVER 146 

Early History of Scarlet Fever, 147 

Division of Scarlet Fever into Species, 151 

Scarlatina Mitis, 151 

" Anginosa, 153 

Affection of the Throat, 156 

Implication of the Eye, 158 

Cerebral Complication, . . . . . . . . .159 

Affection of the Heart, 160 

Angina Maligna Putrida, • . 161 

Sequelae of Scarlet Fever, 164 

Scarlatinal Dropsy, .......... 167 



CONTENTS. 



Page 
LECTURE VIII.— PATHOLOGY, STATISTICS, AND TREAT- 
MENT OF SCARLET FEVER 172 

Statistics of Scarlatina, 174 

Per Centage of Mortality, 176 

Diagnosis of Scarlatina from Measles, 179 

Pathology of Scarlatina, 180 

Laws of the Scarlatinal Miasm, 183 

Recurrence of Scarlatina, ......... 184 

Management of Scarlatina, 186 

Employment of Emetics, 188 

Cold Affusion, 189 

Blood-letting, 190 

" Purgatives, 194 

" Stimulants, 195 

Management of Scarlatinal Dropsy, 198 

LECTURE IX.— ERYSIPELAS 203 

Etymology of Erysipelas, 204 

Ancient Opinions concerning it, 205 

Modern Views of Erysipelas, 207 

Its Origin from Hospital Miasm, 208 

Development of Ochletic Miasm, 210 

Contagiousness of Erysipelas, 213 

Sources of Erysipelas, not Miasmatic, 215 

Incubation, 217 

Phenomena of erysipelas, 220 

Its Extension to Internal Structures, 224 

Statistics of Erysipelas, 226 

Treatment, 228 

LECTURE X.— HISTORY, PHENOMENA, AND PRACTICE OF 

VACCINATION, 237 

Early History of Cow Pox 238 

Announcement and General Adoption of Vaccination, .... 240 

Susceptibility of Cow Pox, 243 

Phenomena of Vaccination, ......... 244 

Constitutional Symptoms accompanying Cow Pox, .... 246 

Anomalies and Varieties, 248 

Concurrence of Cow Pox with Small Pox, 251 

Modified Cow Pox, 254 

Surgery of Vaccination, 255 

Preservation of Vaccine Lymph, . . 261 

LECTURE XL— PATHOLOGY AND RESULTS OF VACCINA- 
TION 262 

Theory of the Identity of Small Pox and Cow Pox, .... 263 

Variolo-Vaccine and Retro-Vaccine Lymph, 266 

Equine Origin of Cow Pox, 268 

Doctrine of Antagonism, ......... 270 

Results of Vaccination, 272 

Variolous Epidemics since 1800, 274 

Statistics of Small Pox after Vaccination, 277 

Per Centage of Mortality, 285 

Actual Amount of Vaccine Security, 287 

Recurrence to the Cow for Primary Lymph, ..... 287 
Re-vaccination, 289 

LECTURE XII.— VESICULAR ERUPTIONS 292 

Varicella, its early History, 292 

Appearance and Progress of Varicella, 296 



xu 



CONTENTS. 



Diagnosis of Varicella and Modified Cow Pox 
Question of its Identity with Variola, 

Herpes 

Herpes Zoster, ...... 

Treatment of Herpetic Eruption, 



Page 
. 299 
. 300 
. 302 
. 303 
. 308 



Miliaria, 308 

Appearances of Miliary Eruption, 310 

Cause of Miliary Eruption, ' 312 

Pemphigus and Pompholyx, . . 314 

Pemphigus, Chronic form of, 314 

" Acute form of, 315 

" Gangrenosus, 315 

LECTURE XIII— NON-CONTAGIOUS EFFLORESCENCES. . . 317 

Lichen, - . . . . 317 

Diagnosis of Lichen Febrilis, 320 

Strophulus, or Infantile Lichen, 321 

Syphilitic Lichen, . . . 322 

Lichen Tropicus, 323 

Urticaria ; its Characters, 324 

Causes of Urticaria, 325 

Roseola : its several Varieties, 327 

Roseola Exanthematica, 327 

Erythema : Local forms of, 329 

Erythema Nodosum, 331 

Connexion of Fever, Efflorescence, and Specific Exanthem, . . . 332 

APPENDIX 333 

Table of average Exanthematic Mortality in New York, Philadelphia, and 

Boston, ............ 333 

Table of Exanthematic Mortality in New York from 1805 to 1850, inclusive, 335 

Philadelphia from 1807 to 1846, " 337 
Boston from 1811 to 1850, " 338 

Providence (R. I.), from 1842 to 1849, 

inclusive, ..... 340 

Lowell (Mass.), from 1839 to 1850, 

inclusive, ..... 340 

Baltimore, from 1836 to 1849, inclusive, 341 
Charleston (S. C), from 1822 to 1849, 

inclusive, ..... 342 

" " Massachusetts (exclusive of Suffolk Co.), 

from 1841 to 1848, inclusive, 



Co-existence of febrile exanthemata, 

Secondary occurrence of small pox, . 

Communication of small pox to foetus in utero 

Means to prevent pitting in small pox, 

Influence of inoculation on mortality, . 

Pathology of scarlatinal dropsy, . 

Treatment of scarlatinal dropsy, . 

On epidemic erysipelas, and the form popularly known 

On mortality by small pox after vaccination, 

On Re-vaccination, ..... 



Black Tongue,' : 



343 
344 
346 
348 
351 
353 
355 
357 
358 
365 
370 



ON THE 

ERUPTIVE FEVERS. 

LECTURE I. 

CHARACTER AND AFFINITIES OF THE ERUPTIVE 
FEVERS. 

Mutual relation of diseases. Importance of the skin in the animal economy. 
Varieties of cutaneous disease. Exanthematic mortality throughout Eng- 
land, and in the metropolis. General character of the exanthemata. Of 
exanthematous fever, its uniformity and steadiness of course. Fever not 
essential to exanthemata. Symmetrical disposition of exanthematous 
eruptions. Alleged identity of the exanthematic poisons. Law of sus- 
pension. Affection of mucous surfaces accompanying exanthemata. 
Structures secondarily implicated. Variety and occasional severity of 
such complications. 

If there be any group or class of disorders which admits 
of being considered apart from and independent of 
others, it is undoubtedly that association of complaints 
called the exanthemata, or eruptive fevers. The reason 
is this. There are many pathological principles which 
are best exemplified in the phenomena of the exanthe- 
mata, and some which are nearly peculiar to them. 
Nevertheless, while I acknowledge this, I would at the 
same time impress upon you the great principle, that 
there are no diseases strictly isolated from others ; they 
are links in a chain — 

" All are but parts of one stupendous whole !" 

They must be viewed in conjunction, if we would hope 

1 



2 MUTUAL RELATION OF DISEASES. 

to form just, enlarged, and legitimate views of the cha- 
racter and pathological affinities of each. 

Let us ask ourselves, what would be the conduct of 
a judicious traveller, when he first sets foot in an inte- 
resting district of country 1 Would he not look out 
for some elevated point, some pinnacle or cloud-capt 
tower, from whence he may survey the general aspect 
of the country, trace the course of the rivers, and the 
direction of the mountains, — from whence he may note 
how the district is indented, on the one hand, by the 
countries he has already traversed, and how it loses 
itself, on the other, in those portions of the country 
which he has still to explore 1 

That which would be a prudent course in the tra- 
veller would be an equally prudent course with us. You 
have studied some portions of the great field of patho- 
logy ; others remain for future investigation. Let it be 
our business now to take a general view of the exanthe- 
mata, in relation to other branches of pathological 
study. It can be but a bird's eye view that I lay 
before you, but such a sketch, loose and imperfect as it 
must necessarily be, will prove useful to us, I had 
almost said essential, in the further prosecution of our 
design. 

Let us, then, consider the relation in which the 
exanthemata stand, 1. to each other ; 2. to other forms 
of fever ; 3. to other diseases of the superficies ; 4. to 
other diseases arising from morbid poison ; 5. to the 
diseases of other structures. 

On the structure of the skin, or dermoid tissue, I 
have no intention to enlarge. That subject has been 
already brought before you in the lectures of Mr. 
Grainger. You will remember what was said of the 



PHYSIOLOGY OF THE SKIN. 6 

epidermis, of the corion or true skin, and of the muci- 
fonn tissue, called rete mucosum, interposed between 
them. You will bear in mind what you were taught 
regarding the blood-vessels and nerves of the skin. 

But though I shall pass over in silence the anatomy 
of the skin, I must detain you for a few minutes while 
I direct your attention to some points in its physiology. 
The skin, you know, is the great organ of transpiration. 
By means of the skin, the body loses every twenty-four 
hours not less than thirty ounces of matter, — very nearly 
two pounds. • 

[Very different results have been arrived at by those who have made 
experiments for the purpose of ascertaining the amount of matter 
thrown off from the skin. M. Seguin fixed the quantit} 7 , taking the 
average of his experiments, at eleven grains per minute, in a grown 
person, or more than two pounds in twenty-four hours. 

Dr. William Wood, of Newport (England), makes it about forty-five 
ounces, or nearly four pounds every twenty-four hours. (Essay on 
Structure and Functions of Skin. Edinb., 1832 : quoted by Dunglison. 
Physiology, 1850.)] 

The skin is exposed to the atmosphere, and to the 
moisture which the atmosphere contains, and to all its 
other influences. It must be, and it is, fitted to bear 
the extremes of temperature which the meteorologist 
registers. You are aware that there are at least a 
hundred degrees of difference between the heats of 
Calcutta and the snows of Caubul. The skin, too, 
is exposed to various injuries, for by the sweat of 
man's brow he is to earn his daily bread. It is also 
supplied with abundant means for the repair of those 
physical injuries. Its numerous blood-vessels are 
endowed with a strong disposition to heal by the first 
intention (adhesive inflammation), or failing that, by 
the second intention, by which is understood the pro- 
cesses of abscess, granulation, and cicatrization. 



4 VARIETIES OF CUTANEOUS DISEASE. 

If you wish to satisfy yourselves of the immense 
importance of the skin in the animal economy, observe 
the effects of burns and scalds. See how a severe burn 
affects the heart, and the brain, and the lungs ; I may 
now say, also, the duodenum ; for the inquiries of Mr. 
Curling have lately added this viscus to those which 
severe injury of the skin disturbs and disorganizes. A 
man may lose one half of his lungs by slow ulceration, 
and he may yet live for months, nay, for years. But if 
one half, or one third, or even one fourth of the skin of 
the body be destroyed, the system rapidly gives way, 
and death ensues. 

The skin may be considered as the fourth in the 
series of important organs. First come those of the 
encephalon, then ihose of the chest, then the abdominal 
organs, and lastly, the superficies. This portion of our 
frame, the superficies, is subject to various diseases 
originating from internal and obscure causes. They are, 

1. The acute febrile affections bringing life into 
hazard. We call them the Exanthemata, from the 
Greek avdos, a flower. Hence sgavdew, to bud forth or 
effloresce. Of these greater exanthemata there are 
four : — Small Pox, Measles, Scarlet Fever, and 
Erysipelas. 

2. The acute febrile affections not bringing life into 
hazard, — the lesser Exanthemata. They are divisible 
into two sections. 1. Vesicular affections, of which 
there are four: — Vaccinia, Varicella, Herpes, and 
Miliaria. 2. The simple efflorescences, not leading to 
fluid effusion ; of which there are also four — namely, 
Lichen, Urticaria, Roseola, and Erythema. These 
twelve forms of eruptive fever will constitute the sub- 
jects of the present series of lectures. 

3. The chronic cutaneous affections of a mild or 



EXANTHEMATIC MORTALITY. Q 

benignant character, formerly characterized as heing 
boni moris : such as Lepra, Psoriasis, Ichthyosis, Impe- 
tigo, Elephantiasis, and Molluscum. 

4. Chronic cutaneous affections, mail moris, bearing 
a malignant character, such as Cancer, Lupus, and 
Fungus nematodes. Complaints of this latter kind are 
exclusively surgical. The physician is consulted in all 
the others. 

I have said that the greater exanthemata are those 
which bring life into hazard. The first point, there- 
fore, to which I have to call your attention, and which 
strikingly displays the relation of the exanthemata to 
each other, is exanthematic or epidemic mortality : 
what is its amount 1 — what proportion do deaths by the 
exanthemata bear to the deaths by all other diseases ? 
Is this proportion constant or fluctuating ] Is it alike 
in town or country 1 I will tell you. 

Upon an average of years, 350,000 persons die 
annually throughout England and Wales, and 46,000 
in the metropolis. The mortality by the four great 
epidemic maladies (small pox, measles, scarlatina, and 
hooping cough) is very nearly 40,000 in England and 
Wales, and about 5000 in the metropolis, averaging 
one in nine of the total mortality, or eleven per cent. 
This is a very large proportion. That four diseases 
only should absorb one ninth of the total mortality of 
this and probably of all other countries, may well excite 
our surprise. 

[The average mortality by these four great epidemic diseases in 
New York, during the forty years from 1806 to 1845 inclusive, was one 
in about thirteen (12f) of the whole mortality, or nearly eight per 
cent., and in Philadelphia, during the thirty years from 1816 to 
1845 inclusive, one in thirteen and a half, or seven and one third per 



EXANTHEMATIC MORTALITY. 



cent. In both these cities, the proportion was one third more during 
the last two decennial periods (from 1826 to 1S35) than during the 
period from 1816 to 1825. In Boston, the deaths by these diseases 
from 1831 to 1840 inclusive, amounted to one in nearly nine and a 
half, or over ten and a half per cent, and from 1841 to 1845 inclusive, 
one in about eight, or a little more than twelve per cent. See Table 
A in Appendix.] 

If the exanthemata are considered independent of the 
hooping cough, considerable fluctuations will be per- 
ceived, the mortality by them falling sometimes as low 
as six per cent, at times rising to near thirteen ; but a 
very important principle comes into play here, which 
serves to equalize the amount of epidemic mortality. 
This curious doctrine had long been surmised, but was 
never proved until the statistical inquiries of recent 
times showed its correctness. We may, for want of a 
better name, call it the law of vicarious mortality, by 
which is understood, that whenever one epidemic 
diminishes, another increases, so that the sum total of epi- 
demic mortality remains, on an average of years, nearly 
the same. The following table exemplifies this : — 

Table exhibiting the amount of Epidemic Mortality in England and 
Wales, during the years 1838, 1839, 1840. 



Small Pox .... 
Measles ..... 
Scarlet Fever .... 

Total mortality by the Exan- ) 
themata . . . . ) 
Hooping Cough .... 

Total of Epidemic Mortality 

Total Mortality throughout ( 
England and Wales . ) 


Year 
1838. 


Year 
1839. 


Year 
1840. 


16,268 
6,514 
5,802 


9,131 
10,937 
10,325 


10,434 

9,326 

19,816 


28,584 
9,107 


30,393 
8,165 


39,576 
6,132 


37,691 


38,558 


45,708 


342,529 


338,979 


359,561 



EXANTHEMATIC MORTALITY. 



We learn from this table, that every year is dis- 
tinguished by some master epidemic. In 1838, small 
pox was the ruling epidemic throughout England. In 
1839, measles and scarlet fever struggled for the mas- 
tery. In 1840, scarlet fever was so general, and so 
fatal, that the mortality by it exceeded by one fifth the 
ravages of small pox during an epidemic season (1838), 
and more than doubled the mortality by that disease in 
1839. 

The following table, exhibiting the amount of epi- 
demic mortality in the metropolis during a period of 
five years, shows that the same general principle applies 
to town and country, but is less manifest in the smaller 
population. 

Table showing the amount of Epidemic Mortality in England during 
Five Years— 183 8 to 1842. 



Small Pox . 

Measles 
Scarlet Fever 

Total Mortality by the ) 
Exanthemata . . ) 
Hooping Cough 

Total of Epidemic Mor- ) 
tality . . . j 

Total Mortality through- ) 
out London . . ) 


Year 
1838. 


Year 

1839. 


Year 
1840. 


Year 
1841. 


Year 
1842. 


3,817 

588 

1,524 


634 
2,036 
2,499 


1,235 
1,132 
1,954 


1,053 
973 
663 


360 
1,292 
1,224 


5,929 
2,083 


5,169 
1,161 


4,321 
1,069 


2,689 
2,278 


2,876 
1,603 


8,012 


6,330 


5,390 


4,967 


4,479 


52,698 


45,441 


46,281 


45,284 


45,272 



From this table we learn that in 1838 small pox was 
the great epidemic in London as in the country. In 
1839, measles and scarlet fever were both on the 
increase, while small pox had sunk from 3817 to 634. 
In 1840, scarlet fever predominated. In 1841, hooping 



8 EXANTHEMATIC MORTALITY. 

cough doubled its numbers, and shot above all the rest ; 
while scarlet fever sank to the low point which small 
pox had reached in 1839. The year 1842 has been 
remarkable, first, for the extreme infrequency of small 
pox, one death only throughout this great metropolis 
being attributed to it for each day of the year ; and 
secondly, for the uniform rate of mortality occasioned 
by its three great rivals. 

[In Appendix B, will be found tables showing the amount of 
epidemic mortality in the cities of New York, Philadelphia, Boston, 
Providence, Lowell, and Charleston (S. C), and in the State of Massa- 
chusetts (exclusive of Suffolk County), during different series of years in 
the different cities, from 1805 to 1849 inclusive. 

It may be seen by reference to these tables, that scarlet fever was the 
predominating disease in the first three of these cities during the five 
years referred to by our author, except in Philadelphia during 1841, 
and in Boston during 1840, in both which years small pox exceeded it 
in mortality — that small pox increased nearly four-fold in New York in 
1840, and in Philadelphia in 1841, and nearly two-fold in Boston in 
1840 — and that in 1838, when it was the great epidemic in London, 
the whole number of -cases in New York and Philadelphia was only 
about one third of that of scarlet fever, and in Boston only 3 to 106 of 
that disease. 

It will also be seen that there was a great increase of mortality by 
small pox in New York in 1834, '5, '6, '7, and in Philadelphia in 1833, 
? 34, while there was no epidemic visitation of it in Boston until 1839. 

In New York and Philadelphia, scarlet fever predominated in 1840, 
as it did in London ; while in 1841, hooping cough was less prevalent 
in each of these three American cities than the other diseases, consti- 
tuting in Philadelphia a proportion of only 6 to a total epidemic 
mortality of 467 ; the next year, however, in the same city, reaching to 
197 out of an epidemic mortality of 597. 

In Baltimore, small pox and scarlet fever were both rife in 1838, 
and the latter was the predominating disease until 1842, during which 
year measles took the lead. 

The same fact with regard to both scarlet fever and measles will be 
found in Charleston, the former prevailing extensively in 1838, when 
the number of cases of measles was only about one seventh ; while in 



EXANTHEMATIC MORTALITY. V 

1842, tlu v number of cases of scarlet fever was just one half that of 
measles.] 

Everything teaches us that when one avenue to death 
is closed, another opens, — 

Noctes atque dies patet atri janua Ditis. 

You will perceive from all this, that vaccination, 
great as its merits are (and no one more fully appre- 
ciates them than I do), does not, and cannot do all that 
its too sanguine admirers promised. The blessings of 
vaccination are met and counterbalanced by the law of 
vicarious mortality. How and why is this 1 The 
explanation is easy. The weak plants of a nursery 
must be weeded out. If weakly children do not fall 
victims to small pox, they live to fall into the jaws of 
tyrants scarcely less inexorable. Scarlet fever and 
measles are both advancing in respect of mortality, and 
the increase of deaths by hooping cough since this 
century set in is quite extraordinary. 

These statistical considerations are both curious and 
instructive, but they are not to diminish our zeal in 
behalf of vaccination, or our efforts to lessen the sum of 
human misery. 

[The subject of vicarious mortality is one of much interest, and one 
which has not received the attention it deserves. Statistics prove that 
the per centage of deaths under five years of age is rather on the 
increase than the contrary, in cities at least ; or, at any rate, remains 
about stationary, and that at a high point in the scale, notwithstanding 
the many lives acknowledged to have been saved by vaccination ; and 
it is no less true, that the mortality by scarlet fever, measles, and 
hooping cough has increased, both in this country and in Europe, 
within the last twenty years. 

It must necessarily be the case that the lives saved from small pox 
increase, by just so many, the number of those who are exposed to 
other causes of death ; and if the susceptibility to each exanthem be the 



10 CHARACTER OF THE EXANTHEMATA. 

same, the balance of life among- those who suffer most by these dis- 
eases would naturally remain the same, so far as this class of causes is 
concerned, supposing them to prevail with equal fatality at all times. 
But other elements must enter into the calculation. The diminution in 
the number of victims of small pox and the increase of mortality by the 
other exanthems, at any particular period, will be governed also to a 
certain extent by the absence of epidemic prevalence of the former, and 
the existence of such a prevalence of the latter. It is, therefore, neces- 
sary to examine the subject in several points of view, and also to extend 
the investigation over a long succession of years, before conclusions 
deserving of confidence can be reached. Even a limited view of the 
subject would require more space than could with propriety be devoted 
to it in this connexion, and we reluctantly dismiss it with this passing 
notice.] 

Dr. Haygarth once inquired what would be the pro- 
bable effect of a complete annihilation of small pox. 
He entertained some extravagant idea of effecting this 
by a plan of universal inoculation. The result of the 
calculation was, that in fifty years more than one eighth 
would be added to the population. On a population of 
sixteen millions (which we now nearly reach), the 
increase in fifty years would therefore be two millions 
and a half. In this calculation, the doctrine of vica- 
rious mortality, though not left out of consideration, 
was, it is plain, prodigiously underrated. 

The general character of the exanthemata is derived 
from the following sources : — 1. From the presence and 
course of the accompanying constitutional disturbance. 

2. From the course of the local or cutaneous affection. 

3. From the law of universal susceptibility. 4. From 
the law of non-recurrence. 5. From the law of con- 
tagious origin. 6. From the law of epidemic diffusion. 
Fever, eruption, universal susceptibility, non-recurrence, 
contagion, epidemic diffusion — these are the topics 



CHARACTER OF THE EXANTHEMATA. 11 

which in the course of this and the succeeding lecture 
are to occupy our thoughts. They will he found to 
involve a great variety of important and some very 
curious considerations, all equally necessary to a due 
understanding of the exanthemata. 

1. The exanthemata are usually described as fevers 
to which eruption is essentially linked. The old 
authors used the phrases febris variolosa, febris rubeo- 
losa, febris anginosa, and erysipelatosa, when speaking 
of these disorders. As the doctrines of fever have not 
yet been formally explained to you, I may premise that 
by fever we mean a general disturbance of the whole 
system, affecting principally the heart, lungs, brain, and 
secreting organs, but extending, more or less, to every 
structure and function of the body. The four leading 
features of fever are — 1. Rigors, succeeded by or alter- 
nating with flushes. 2. Frequency of pulse. 3. Las- 
situde and debility. 4. Diminished and depraved 
secretion. When a man has a hot skin, a frequent 
pulse, a furred tongue, and a feeling of weariness, we 
say that he has an attack of fever. The lesser symp- 
toms are, restlessness, disturbed dreams, wandering 
pains, especially of the back and limbs, thirst, and loss 
of appetite. 

Fever is of several kinds, types, or characters. We 
distinguish four great types of fever, the inflammatory, 
the nervous, the gastric, and the malignant, in which 
respectively the heart, the brain, the intestinal canal, 
and the blood itself are more directly and severely im- 
plicated. The true character of exanthematous fever is 
inflammatory. This it exhibits in nineteen twentieths 
of the cases of small pox and measles. The low or 
nervous form of fever occasionally characterizes scarla- 



12 



EXANTHEMATOUS FEVER. 



tina and erysipelas. The putrid, petechial, or malignant 
form of fever is occasionally witnessed both in small 
pox and scarlatina In these cases the blood is literally 
poisoned. It loses its ordinary powers of coagulation, 
bursts through its containing vessels, and appears in the 
form of petechia? and haemorrhages. It is a curious 
circumstance that the vaccine poison, mild as it is to 
the greater number of mankind, may yet in the same 
manner poison the blood. I have lately attended a 
case of petechial cow pox — an occurrence hitherto 
unrecorded. It is far from an improbable supposition, 
that in the worst of these cases the vitality of the blood 
is actually destroyed, and that death takes place in 
consequence of the circulation of blood, the vital pro- 
perties of which are extinct. 

Exanthematous fever is divided into stages. I shall 
have to speak to you of four stages — the incubative, 
eruptive, maturative, and secondary. The incubative 
stage, commonly called the period of breeding, is of two 
kinds, the silent and the overt ; that is, it is sometimes 
attended, sometimes unattended by symptoms. The 
processes of eruption and maturation have likewise their 
respective fevers, called the eruptive and maturative 
fever. The term secondary fever expresses that renewal 
or exacerbation of febrile symptoms w T hich happens 
when the specific fever ought, normally, to subside. It 
is commonly applied to small pox, but I shall have 
occasion to show you that each exanthema has its stage 
of secondary fever, characterized by a certain group of 
symptoms. Here we trace another important bond of 
connexion among the exanthemata. 

Nothing is more striking than to witness the uni- 
formity in the character of exanthematous fever, under 



ITS UNIFORMITY AND STEADINESS. 13 

every possible variety of external circumstance. Neither 
age, season, climate, nor habit of body, affects materially 
the phenomena of small pox and measles. The 
description of the exanthemata handed down to us from 
the Arabians, corresponds perfectly with the appear- 
ances which we now witness: the European and the 
negro, the infant and the aged man, the strong and the 
feeble, suffer alike. The chief modifications of exanthe- 
matous fever are the result either of idiosyncrasy or of 
a habit of body artificially engendered. 

The peculiarly steady course of exanthematous fever 
enables us to predict the result, or, as we commonly 
say, to prognosticate, in eruptive fevers, with a certainty 
which it is not permitted us to do in any other tribe of 
diseases. Even the nurses at the Small Pox Hospital 
are rarely deceived. 

The notion that " fever precedes the specific action 
of the exanthematous poisons" has prevailed in all ages, 
and still holds its ground. You will find this doctrine 
distinctlv laid down in jr. Williams's work on the 
morbid poisons. He calls fever the primary effect of 
the poison; affection of the skin and mucous mem- 
branes he calls the secondary effect of the poison ; and 
the inflammation of internal organs its tertiary effect. 

Having mentioned the work of Dr. Williams,* senior 
physician of this hospital, I should be doing injustice to 
my own feelings were I not to say that, in my judgment, 
it is the best specimen of elaborate research, of lucid 
and terse description, and of sound pathology, which 
has appeared in this country — honorable alike to the 
author, to this hospital, and to the age in which we 

* Elements of Medicine. On Morbid Poisons. By Robert Williams, M.D. 
London, 1841. 2 vols. 8vo. 



14 FEVER NOT ESSENTIAL TO EXANTHEMA. 

live. It is a work, which better than any other that I 
know, portrays the style of reasoning on matters of 
pathology prevailing in this country at this time, and as 
such will be quoted in after ages. It should be in the 
hands, not of the student, for he cannot appreciate its 
merit, but of every practitioner in this country, who will 
find in it rich stores of curious anecdote and useful 
instruction. 

High as the authority of Dr. Williams is, I shall 
occasionally venture to dissent from him, and shall do 
so on the present occasion. Dr. Williams, I have told 
you, upholds the ancient maxim that fever precedes the 
specific action of exanthematic poisons. The doctrine 
that I teach you, however, is, that exanthema may take 
place without fever, that the febrile state is not essential 
to the development of exanthem. For observe, — cow 
pox, varicella, inoculated small pox, and the mildest 
type of scarlatina, frequently display themselves without 
initiatory, without eruptive, nay, even without matura- 
tive fever. But further, I shall have occasion to show 
you, that the less the amount of fever the more perfectly 
is the eruption developed, and the more normal is the 
course of the disease. Any tumultuous febrile action 
disturbs the regular progress of an exanthem. Witness 
scarlatina with excessive angina. There is here literally 
no eruption at all. We call the complaint angina 
maligna. Witness the recession of the eruption in 
malignant measles. Witness the ill-developed eruption 
of petechial small pox. This consideration is strictly 
practical. It shows the extreme folly of the old notion, 
that raising a fever by means of warm baths, heated 
rooms, and cordial alexipharmics, promoted eruption. 
It shows you the merits of Sydenham and of Sutton, 



SYMMETRY OF EXANTHEMATA. 11 

who, in consecutive centuries, did so much to improve 
the practice in small pox. It shows you that the 
violence of initiatory fever must often be subdued by 
active purgatives, by leeches, or even by venesection, 
to give the disease any chance of running a safe course. 
As, then, there may be eruption without fever, the 
question may reasonably be asked — May there not be 
the specific fever of an exanthematous poison without 
eruption ? Has a man ever gone through small pox 
and measles without exhibiting eruption 1 In all ages 
this doctrine has obtained some supporters. Sydenham 
encouraged the notion that in epidemic years a variolous 
fever was to be met with which showed no eruption. 
Burserius, Vogel, De Haen, Frank, Hedland, and others, 
have, in later times, avowed their belief in this Irish 
mode of undergoing small pox. Some countenance is 
given to the doctrine by the phenomena of cynanche 
maligna, but it is very questionable pathology, which I 
cannot undertake to advocate. 

[Dr. Watson agrees in opinion with our author on the subject of the 
" variola sine variolis." (Pract. Physic, 3d edit. 147, p. 979.) But a 
recent epidemic of measles in Paris seems to have satisfied those who 
observed it as to the occurrence of the constitutional symptoms of the 
disease without the eruption.] 

2. The second character of the exanthemata is 
derived from the presence of eruption. Here I must 
advert, for a few moments, to a doctrine recently brought 
forward under the title of the symmetry of diseased 
action ; by which is understood the fact, that in disease 
both sides of the body are affected alike. This doctrine 
always reminds me of the lines on Dutch gardening, 
where 

Grove nods at grove, each alley has its brother, 
And half the garden just reflects the other. 



16 SYMMETRY OF EXANTHEMATOUS ERUPTION. 

In the case of this symmetrical disposition of disease, 
we are all, I suspect, pretty much in the same state as 
the Bourgeois Gentilhomme, who found out that he had 
been speaking prose all his life without knowing it We 
knew the facts, but we had never reasoned concerning 
them. The chief illustrations of the symmetry of disease 
are to be found in the phenomena of rheumatism, in the 
mode of decay of the teeth, in the growth of certain 
tumors ; but, better than all, in the aspect of exanthe- 
matic eruption. In the corymbose form of small pox, 
the patches, or corymbi, will be found to correspond 
on the two sides of the body in the most singular man- 
ner. Once I had a patient at the Small Pox Hospital, 
who exhibited confluence in the highest possible degree 
on each hand and wrist, but in no other part of her 
body. 

[For striking illustrations of the symmetrical arrangement which 
patches of eruption assume, with many curious facts and much ingenious 
reasoning on the subject, see Paper on the subject by Mr. James Paget, 
and especially a more extended one by Dr. William Budd, in Medico- 
Cliirurg. Transactions, vol. 25.] 

In all the exanthemata, the parts of the body nearest 
the centre of circulation are more affected than those at 
a distance. This is strikingly exemplified in the erup- 
tion of post-vaccine small pox, which is often confluent 
on the face, and wholly undeveloped on the extremities. 

In general, the distinctive characters of exanthema- 
tous eruption are strongly marked, but difficulties in 
diagnosis do occur. Small pox is sometimes mistaken 
for chicken pox. Measles is not always readily distin- 
guished from lichen. 

When the exanthemata first invaded the world, their 
identity was universally believed. Rhazes and Avi- 



EXANTHEMATIC IDENTITY. 17 

cenna taught that small pox and measles were the same 
disease. Even so late as 1640 this doctrine prevailed 
all over Europe. Measles and scarlatina continued to 
be confounded until about one hundred years ago; nor 
has the bias in favor of exanthematic identity, which 
our ancestors displayed, altogether subsided. Dr. 
Thomson, of Edinburgh, labored to prove that chicken 
pox is identical with small pox. Dr. Baron, Mr. Ceely, 
and others, who would be justly offended by the impu- 
tation of confounding scarlatina with measles, or measles 
with small pox, contend nevertheless strenuously for the 
identity of small pox and cow pox. 

That the disorders termed exanthemata bear a cer- 
tain pathological relation to each other cannot be 
denied, but this principle is probably not more applica- 
ble to small pox and cow pox than it is to small pox 
and measles, to small pox and chicken pox, to measles 
and scarlet fever. The epoch of the diffusion of small 
pox and measles gives a certain countenance to such a 
doctrine. The relationship may possibly consist in 
some modification of the elements which compose the 
morbid miasm, and may be analogous to that which 
subsists between the nitrous oxyde, the nitrous acid, and 
the nitric acid. Such a relationship, however, if admit- 
ted, is very different from the absolute identity for 
which Dr. Thomson and Dr. Baron contend. 

Nothing certain is known regarding the primary 
sources of the exanthematic poisons. The analogy of 
cow pox would lead us to conjecture that all (I mean 
the- variolous, rubeolous, and scarlatinal) were originally 
derived from cattle. Such an idea was entertained long 
before the discovery of vaccination. Dr. Layard, in 
1780, distinctly avowed his belief that the lues bovilla 

2 



18 LAW OF SUSPENSION, 

was of the same nature as small pox. Navier (a French 
author), in 1753, traced the relation subsisting between 
scarlatina and the distemper of horned cattle, and came 
to the conclusion that scarlet fever was originally com- 
municated from cattle to man. 

In some cases the body receives at one and the same 
moment the germs or miasms of two exanthemata, and 
though they occasionally proceed pari passu, the more 
usual law is that of suspension. Generally the lesser 
exanthem is suspended by the greater. Measles is sus- 
pended by small pox. Cow pox is held in abeyance by 
measles; but instances of the reverse proceeding are on 
record. 

[For cases illustrating the co-existence of two febrile exanthemata 
in the same individual, and the suspension of one by another, see 
Appendix C] 

The connexion of exanthematous eruption with a 
like affection of those mucous expansions or tissues 
which are in contact with the atmospheric air, and 
exposed to its direct influences, claims your especial 
attention. It is a feature in the eruptive fevers of the 
highest importance both in theory and practice. A 
reason may be found for this connexion in the similarity 
of the structure and offices of skin and mucous mem- 
brane. The epithelium of the one corresponds with 
the epidermis of the other. The result is, that all such 
mucous membranes are susceptible of the changes of 
efflorescence, papula, vesicle, and pustule. Small pox, 
measles, and scarlatina, alike exhibit, in their early 
stages, affection of mucous surfaces, — either of the nose, 
month, fauces, larynx, or trachea. Erysipelas some- 
times betrays the same tendency, and this strong dispo- 
sition of the morbid poisons to affect the throat is still 



SECONDARY AFFECTIONS. 19 

further exemplified in the phenomena of hydrophobia 
and lues venerea. 

In some cases, the skin receives the whole violence 
of the poison ; sometimes the mucous membrane to the 
exclusion of the skin ; and in a third set of cases, both 
structures suffer. The blood, too, may be primarily 
affected by the poison, even before the development of 
fever (illustrating the principle, that the eruptive nisus 
is independent of fever). But other organs occasion- 
ally suffer, when the miasm is very virulent, or the 
body in an unhealthy state. Here we trace an import- 
ant bond of connexion between the eruptive and other 
kinds of fever. 

[In variola, rubeola, and scarlatina, Andral and Gavarret found the 
composition of the blood very similar to what it is in continued fever. 
Some analyses gave negative results, while in others the tendency of the 
blood was more towards hyperinosis than hypinosis. 

The maximum of fibrin amounts to only 4.4, against which there is 
a minimum of 1.1. In the majority of cases, it does not differ much 
from Lecanu's normal average 3. 

The blood corpuscles are increased in a less degree in variola and vario- 
loid, than in scarlatina and rubeola. (Simon's Chemistry, vol. i. 298.) 

Andral says that he has never met with the buff, unless there was 
some phlegmasial complication, either in inflammatory fever, in slight or 
severe typhoid fever, in measles, in scarlatina, or in variola. (Paiholog. 
Hcematology — translated by Drs. Meigs and Stille, p. 56.)] 

In typhus fever, rheumatic fever, and remittent fever, 
we observe the implication of internal structures. 
These most serious aggravations of eruptive malady, 
whether denominated secondary or tertiary, may occur 
at all periods of the exanthem. They may accompany 
the first burst of eruption ; — they may develope them- 
selves gradually during the maturative stage, or period 
of concoction, but they prevail chiefly towards the 



20 SECONDARY AFFECTIONS. 

decline of the disorder, and in the course of secondary 
fever. 

I know of no exanthem which does not show 
secondary complications, no organ or structure which 
may not thus be dragged, as it were, into participation 
with the primary malady. 

In small pox we see the eye, the salivary glands, the 
brain, the pleura so affected. In measles we see the 
lungs, the larynx, and the mucous membrane of the 
bowels, secondarily affected. In scarlet fever the variety 
is still greater. The eye, the ear, the heart, the liver, 
the kidney, and the peritoneal surface of the bowels, 
are each, in their turn, the seat of superadded disorder. 
In certain cases, the morbid poison acts as directly on 
these internal structures as it does upon the skin ; but 
this is not a normal course of exanthematous disorder. 
The brain is especially liable to suffer in small pox, 
the lungs in measles, and the kidney in scarlet fever. 
When we consider the peculiar offices of the kidney 
and skin, we shall be at no loss to account for the 
implication of the kidney iu a disease which suspends 
the function of the skin so completely as does scarlatina. 
Some of these internal complications, or superadditions 
to exanthematous malady, are explicable on other prin- 
ciples, especially those which occur after the climax or 
crisis ; when the virulence of the poison has, for the 
most part, expended itself. Thus, some are attributable 
to season, some to plethora, some to local weakness, 
the legacy of a prior ailment ; some to the coincidence 
of a typhoid or hospital miasm. The theory of a few 
cases must be sought for yet deeper, and may be found 
in that obscure law of the animal economy which, in 
other diseases, probably through the medium of the 
veins, tends to the formation of purulent depots. 



VARIETY IN THE COMPLICATIONS. 21 

These secondary or superadded effects of the poison 
vary very much in violence. The pleuritic complica- 
tion in the secondary fever of small-pox, the pneumonia 
consecutive of measles, and the dropsy supervening in 
the latter stages of scarlatina, absorb every other con- 
sideration, and prove, in themselves, the direct causes 
of death. But other affections of the surface may take 
place besides the specific affection belonging to the 
miasm. Thus we may have small-pox followed by 
scarlatina — measles by erysipelas and gangrene — scar- 
latina by phlegmasia dolens. Some complications, 
again, are purely accidental, and this happens much 
more frequently in adult than in infantile life. In 
infancy the exanthemata occur for the most part uncom- 
plicated ; but as life advances, the probability increases 
of some accidental complication. Thus, for instance, 
small pox in the adult may be complicated with apo- 
plexy ; measles with phthisis; scarlatina with pregnancy. 
In infancy we sometimes meet with hooping cough 
complicating and thereby aggravating each of the erup- 
tive fevers. Painful dentition, in like manner, may be 
superadded to exanthematic disease, and contribute its 
share to the sufferings of the patient, and the result o{ 
the malady. 



LECTURE II. 

CHARACTER AND MANAGEMENT OF THE ERUPTIVE 

FEVERS. 

Law of universal susceptibility. Law of non-recurrence. Exceptions to 
this law. Of contagion. Miasm or morbid poison. Modes of its access 
to the body. Inoculation. Theory of Zymosis. Absence of predispos- 
ing causes. Of Fomites. Quarantine. Epidemic diffusion. Theories of 
epidemic influence. Laws of epidemic visitation. Management of the 
Exanthemata — during the period of invasion — of maturation and decline. 
Inefficacy of tonics in the secondary fever of the Exanthemata. 
Employment of saline diaphoretics — of opiates. Influence of medicine 
generally on the course of eruptive fevers. 

The eruptive fevers derive their third character from 
the law of universal susceptibility. 

No principle is more generally recognised than that 
small pox and measles necessarily and unavoidably 
occur to every man once in the course of life. The 
notion can be traced back even to the Arabians. Avi- 
cenna distinctly announces the fact, and strives to 
account for it. Willis says, that the escape of a man 
living to the ordinary period of human life from small 
pox and measles, is as rare as the falling into them 
twice. Both the one and the other he describes as 
vara et inusitata eventa. Diemerbroeck is the only 
author I know who distrusted the doctrine of universal 
susceptibility, and he was doubtless influenced by the 
fact that he himself reached the age of seventy without 
ever experiencing an attack of small pox, though so 
continually exposed to the contagion. In the palmy 
days of inoculation, it was found that very few chil- 
dren were permanently unsusceptible, though, of course, 



LAW OF UNIVERSAL SUSCEPTIBILITY. 23 

from temporary causes, the operation occasionally failed 
of success. Dr. Woodville, my predecessor at the 
Small Pox Hospital, estimated the proportion of unsus- 
ceptible children at one out of sixty. The proportion 
of unsusceptible adults was considerably higher, perhaps 
one in twenty. 

There are still some countries in the world not yet 
visited by the exanthemata. Small pox, measles, and 
scarlet fever, are to this day unknown in Australia and 
Van Diemen's Land. 

All the exanthemata have sprung up since the com- 
mencement of the sixth century. The dates of the first 
appearance of each exanthem will be duly investigated, 
as constituting an interesting branch of medical chro- 
nology. That a "nova febrium cohors" should thus 
invade the earth need not surprise us when we reflect 
that, within our own times, two have started into exist- 
ence — Vaccinia and Asiatic Cholera, — the mildest and 
the most malignant of human maladies, the Alpha and 
the Omega in the catalogue of morbid poisons. How 
many more of w r hat Gray describes as 

" The painful family of death, 
More hideous than their queen," 

lie concealed in the womb of time it is not for us to 
say, but we may reasonably conjecture from w r hat we 
know of the origin and succession of epidemic mala- 
dies, that nature has not yet exhausted her store of 
wide-wasting pestilences, and that others remain to 
afford occupation for the pathologists and physicians of 
succeeding ages. 

The fourth peculiarity of the exanthemata is derived 
from the law of non-recurrence. It was formerly held 



24 LAW OF NON-RECURRENCE. 

that scarce any one had small pox or measles a second 
time. This doctrine was sedulously inculcated during 
the greater part of the last century, when the philan- 
thropic mind was laboring to encourage the practice of 
inoculation. 

Dr. Mead of London, the elder Monro of Edinburgh 
(two of the best practical physicians of the last century), 
doubted the possibility of small pox recurring. De 
Haen, De la Condamine, and Dr. Heberden, spoke of 
it as a possible but most unusual event. Times are 
changed. Vaccination has taken the place of inocula- 
tion, and now, to screen the obvious defects in the pro- 
tective power of the cow pox, pathologists have wheeled 
round, and many, in their zeal, would fain persuade us 
that the recurrence both of small pox and of measles is 
far more frequent than our forefathers were willing to 
admit. The friends of vaccination, says Dr. Baron,* 
were compelled to prove that the small pox occurred a 
second time, and in so doing were accused of drawing 
upon their imagination. To determine the truth in a 
matter of such interest may profitably employ a few 
minutes of our time. 

Immunity from second attacks of the same disease is 
a very extended and a very important principle in 
pathology. It does not merely apply (as the world 
would have us to believe) to small . pox, measles, and 
hooping cough, but to all diseases whatever which origin- 
ate from a poison or miasm — which are, as we say, of 
miasmatic origin. It belongs, therefore, to scarlet fever, 
yellow fever, typhus fever, and Egyptian plague. It 
belongs, in a certain limited degree, to fevers of paludal, 
terrestrial, or, as we sometimes say, of endemic origin — 

* Baron's Life of Jenner, vol. i. p. 226. 



ORIGIN FROM CONTAGION. 25 

that is, to ague and remitting fever ; for these fevers arc 
curable while the patient is still resident in the 
unhealthy locality, and a certain time elapses before the 
constitution is susceptible of a second seizure. So also 
with gout and rheumatism, fevers of internal origin. It 
is well known that these diseases recur again and 
again, and at length rivet themselves on the system. 
Nevertheless, we congratulate a friend, with perfect 
justice, w r hen we hear that he has had a fit of the gout, 
because we feel sure that for a certain time he will be 
free from similar attacks. In all cases, therefore, the 
susceptibility of a disease is more or less exhausted by 
once undergoing it. A gradation in this respect may 
easily be traced from rheumatism and gout (where the 
law obtains least) through ague and every variety of 
endemic fever, whether remittent or continued, up to 
plague, scarlet fever, typhus, yellow fever, measles, and 
small pox. The law of non-recurrence is more strik- 
ingly displayed in measles and small pox than in any 
other known disorder. Nevertheless, exceptions occur 
even here, of which due mention will be made in future 
parts of the course. 

We now approach the fifth characteristic of the 
exanthemata — contagious origin. 

The diseases of the human body are divisible into 
two great classes — those of constitutional and those of 
accidental origin. This distinction is very obvious in 
surgery. Cancer, fungus nematodes, stone in the 
bladder, white swellings, psoas abscess, aneurisms, — all 
arise from internal causes, and are of constitutional 
origin Again, fractures, dislocations, sprains, wounds, 
burns, scalds, and contusions, are the result of external 
and accidental causes. In a community where there 



26 ACCESS OF CONTAGION TO BODY. 

were no railroads, no runaway horses, no high scaffold- 
ings, no deep mines, no cotton mills, and no careless 
servants, a surgeon might practise for many years 
without ever meeting with any disorders but those of 
constitutional origin. 

Now the same distinction holds good in physic. 
There are medical as well as surgical accidents. Drop- 
sies, inflammations, haemorrhages, apoplexy, palsy, and 
jaundice, are all constitutional maladies, arising from 
such internal causes as the following: — Advancing age, 
scrofula, original weakness of constitution, the gouty or 
rheumatic diathesis imprinted on the individual at birth 
and descending to him from his parents. 

The second class of medical disorders are those of 
accidental origin — the results of overfeeding, of intem- 
perance, of exposure to cold, of excessive fatigue, but 
above all, of those deleterious agents received into the 
body from without, which we call miasms or poisons. 
The most interesting disorders belonging to this class 
are the exanthemata ; but, besides them, we enumerate, 
as associated with them, the venereal disease, gonor- 
rhoea, hydrophobia, hooping cough, plague, and some 
others of lesser moment. These all originate from the 
miasms of an animal body laboring under disease, and 
we therefore call them the true morbid poisons. Ague, 
remittent fever, dysentery, and cholera, arise from ter- 
restrial miasm. In Dr. Williams's work, however, you 
will find all these diseases treated of under the general 
appellation of the " morbid poisons." 

The contagion, infective miasm, or materies ??iorbi, 
obtains access to the human body in three modes. First, 
by the inhalation of air tainted by the breath or perspi- 
ration of a patient. This is called the mode of infec- 



INOCULATION. 27 

tiou. Small pox, measles, plague, typhus, scarlatina, 
and erysipelas, are thus communicated. Experiments 
have been made to determine the limit of infective 
distance, but nothing very satisfactory is known con- 
cerning it. It probably varies from a few feet to many 
yards. 

2. Miasms gain access to the body, secondly, by solu- 
tion in the fluids, or humors, and subsequent application 
to the unbroken surface. It is thus that psora, tinea 
capitis, gonorrhoea, and the venereal disease, are com- 
municated from man to man. We call this mode 
contagion, " a contactu corporis? Remember that the 
materies in orb i must be dissolved. " Corpora non agunt 
nisi soluta," was a dogma of the old chemists. It is 
equally true of the animal body. Fluidity is essential 
to all the great processes going on within the animal 
economy, a principle which those who vaccinate from 
points and glasses are very apt to forget. The germ of 
disease is conveyed in the fluid form in the interior of 
the frame, where it mixes with and taints the blood, the 
most complex, the most perfect, and the most essential 
to life of all the animal fluids. 

Strongly impressed with the importance of these 
things, the ancient physicians professed themselves 
humoral pathologists, and the current of modern disco- 
very is running rapidly into the same channel. Witness 
the importance attached to the condition of the urine in 
disease, and observe with what interest all microscopical 
observations on , the blood and its secretions are now 
received. 

3. Certain of the morbid poisons are not admitted 
into the frame unless (still after solution in the animal 
fluids) they are applied to an abraded or wounded sur- 



28 INOCULATION. 

face. Hydrophobia, vaccinia, and farcinoma (or glan- 
ders), are received in this mode. Small pox and plague 
may thus be excited artificially, and the process is, as 
you know, called inoculation. 

One of those curious points in pathology which is 
now attracting the attention of Continental physicians, 
is the direct communication of disease by means of the 
blood, and not by the secretion derived from the blood. 
It is very reasonable to suppose that such may be the 
law of nature. All infection is probably direct from the 
blood. The injection of the blood of a glandered horse 
into the veins of a healthy horse communicates that 
disorder. Measles has been communicated by inocula- 
tion with the blood in so many instances, and by so 
many experimenters, and recently in the Austrian terri- 
tories on so large a scale, that no doubt can exist as to 
the possibility of thus exciting the disease. I have often 
noticed that if the vaccine vesicle be punctured so deeply 
as to bleed, the lymph is equally effective as when per- 
fectly colorless and pure. All these things point to an 
important principle — the direct communication of dis- 
ease by means of the blood. Whether the resulting 
disorder be thereby rendered milder, as in the ordinary 
process of inoculation from secreted humor, or not, is a 
question for our future consideration. 

Each specific miasm has its respective laws — its 
period of latency, of development, and of decline. With 
reference to the period of incubation, the morbid miasms 
are divisible into three classes : — 

1. Those of rapid incubation — viz., chicken pox, 
plague, scarlatina, and gonorrhoea. In these instances 
the latent period is less than a week. 

2. Those of mature incubation, the period extending 



THEORY OF ZYMOSIS. 29 

from ten to fourteen days. In this class come small 
pox, measles, and hooping cough. 

3. Those of tedious incubation (extending from four 
to six weeks). In this class we place hydrophobia, 
secondary syphilis, and endemial remittent. 

From the earliest period at which the existence of 
morbid poisons became known, the analogy of vegetable 
fermentation has been adduced to explain their modus 
operandi. The doctrine of a fermentative process going 
on during the incubation of small pox and measles, was 
distinctly announced by Sydenham, Willis, Diemer- 
broeck, and Morton. Liebig has lately given increased 
interest to this portion of pathology, by reviving the 
hypothesis of fermentation, and investing it with a sci- 
entific character. " The phenomena attending the 
transformation of organic vegetable compounds afford," 
he says, " not merely an analogy, but a correct explana- 
tion of the changes taking place in the animal economy 
by the agency of morbid poisons." Nothing, however, 
can be clearer than that in this notion, whether correct 
or not, Liebig is anticipated by Diemerbroeck, who 
flourished two hundred years ago. " Out of an infected 
body," says he, " flow forth continual streams, which, 
being received by other bodies, presently ferment with 
the blood, and excite the latent and homogeneous seeds 
of the same distemper, disposing them into the idea or 
character of the same disease." 

Mr. Farr, in his fourth report, recently submitted to 
parliament, proposes to call all those diseases which 
have the property of communicating their own action, 
and effecting analogous transformations, zymotic dis- 
eases (from W ou i to ferment), and the action itself, 
zymosis. Zymotic diseases will comprehend all those 



30 QUARANTINE. 

now associated by the tedious periphrasis of " epidemic, 
endemic, and contagious maladies." The terms appear 
to me to be judiciously chosen, and I shall employ 
them in these lectures. Zymosis, you will remember, 
is applied to a process of the animal economy ; fer- 
mentation to the mutual action of vegetable principles. 

One very remarkable character of the zymotic 
miasms is, that they operate upon the healthy body 
without the aid of predisposing causes. A man in the 
most perfect health contracts small pox or measles, and 
this state of body is the best possible for insuring the 
success of inoculation and vaccination. Almost all 
cases of vaccination which progress unfavorably, may 
be traced to some previously unhealthy condition of 
the humors or secretions. A characteristic feature, 
then, of the exanthemata is "absence of predisposing 
causes? 

All miasms of animal origin are capable of attaching 
themselves to fomites, and (provided they be excluded 
from the air) of retaining their communicating property 
for a considerable length of time. This great law of 
nature is the foundation of that important practical 
measure — quarantine. It is a law of universal applica- 
tion. Tinea capitis spreads by means of hats, combs, 
and brushes ; Egyptian ophthalmia by towels and 
sponges ; small pox and typhus by clothes and bedding ; 
plague by personal apparel and old rags. Some would 
persuade us that merchandise, which, ex necessitate rei, 
could never have been near the chambers of the sick, or 
handled by others than by men in health, may also com- 
municate contagion ; but I believe this doctrine to be 
opposed to every principle in sound pathology. 

Reasoning chiefly from the well established fact that 



QUARANTINE. 31 

medical men very seldom communicate the seeds of 
disease, Dr. Haygarth discredited the doctrine of com- 
munication by fomites. That fact, though it will not 
bear out Haygarth in his speculations, sufficiently proves 
how exceedingly volatile contagious miasms are, and 
how short an exposure to the air deprives them of 
noxious quality. The term of forty days, originally 
judged necessary for the security of the community, is 
founded on utter ignorance of the laws of morbid Doi- 
sons. As the incubative stage of plague never exceeds 
seven days, so one week of quarantine is, in strictness, 
sufficient, and two weeks should satisfy the most scru- 
pulous anxiety. 

[The Commission of the French Academy of Medicine, appointed in 
1844 to report on the subject of Plague and Quarantines, say that at a 
distance from countries where it is endemic, and beyond or away from 
epidemic foci, the plague has never broken out in persons who have 
been exposed to its influence after an isolation of eight days.] 

The period of quarantine, too, may safely commence 
from the departure of the ship from the suspected port. 
This great improvement in commercial intercourse is 

now sanctioned bv the British Government. 

j 

You will take notice, that all fomites or harborers of 
contagion are substances of a rough surface or downy 
texture. Wool, cotton, leather, every kind of apparel, 
the dust accumulated on walls, floors, and ceilings, are 
those against which it behoves you to be most on your 
guard. By universal consent it is admitted that money 
and all metallic substances are incapable of harboring 
contagion. 

6. The sixth and last character of the exanthemata 
is drawn from their occurrence as epidemics. This 
term is derived from the Greek words =*« and hy<%, and 



32 THEORY OF EPIDEMIC INFLUENCE. 

simply expresses the fact of the spreading of a disease 
among the people without reference to the precise mode 
of communication. Some diseases therefore are conta- 
gious but not epidemic, as ophthalmia, gonorrhoea, and 
porrigo. Some are epidemic but not contagious, as 
catarrh, diarrhoea, and pneumonia. 

Lastly, some diseases are both epidemic and con- 
tagious, as small pox, measles, scarlet fever, typhus 
fever, plague, and probably also cholera. These are the 
diseases which, rising occasionally like a mist out of 
the earth, shed desolation on nations, to disappear as 
rapidly and insensibly as they arose. The origin of all 
such disorders is necessarily obscure, but the obscurity 
has proved no stumbling-block in the path of medical 
theorists. In ancient times their appearance was attri- 
buted to the direct agency or influence of the sun, moon, 
and stars (whence the term influenza, applied to the 
least energetic among them). Sydenham connected 
them with some supposed movements going on below 
the earth's surface, in ipsis terra? visceribus. Some 
modern pathologists attribute them to the condition of 
the surface itself; some find, or pretend to find, their 
source in mysterious changes of the atmosphere ; others 
in heat, imperfect ventilation, or some bad quality of 
food. Dr. Holland looks with favor on the animalcular 
origin of epidemic maladies, while Diemerbroeck can- 
didly avows his belief that this is one of those mysteries 
which nature for ever intends to keep to herself. 
• The present most approved theory of epidemic 
influence attributes everything to the atmosphere, but 
neither the thermometer, nor the barometer, nor the 
hygrometer, nor the electrometer, aids us in our re- 
searches. The best prospect of attaining to truth in 



EPIDEMIC INFLUENCE. 33 

this recondite branch of pathology is afforded by the 
increasing fondness for statistical researches. Their 
improvement and extension to eastern countries, where 
all wide-spreading epidemics seem to originate, may 
perhaps discover order where all is now confusion and 
vague conjecture. 

Seven maladies are acknowledged on all hands as 
genuine epidemics. These are Small Pox, Measles, 
Scarlet Fever, Hooping Cough, Typhus, Cholera, 
and Influenza. The Registrar-General of England 
admits, in his Statistical Reports, four other disorders 
into the category of epidemics, namely : — croup, thrush, 
diarrhoea, and dysentery. Their claims to this distinc- 
tion are not, however, so generally conceded. At any 
rate, on the same grounds, pneumonia might lay claim 
to the title of an epidemic. 

Although we make no pretensions to a knowledge 
of the ultimate cause of epidemic visitation, yet there 
are certain laws, having reference to the diffusion of 
epidemics, which are sufficiently established. 

It is seldom that two diseases are epidemic at the 
same time in the same district. When the yellow 
fever raged with such violence at Gibraltar in 1804, it 
was remarked that all other diseases declined ; and well 
they might, for in that fatal epidemic, out of a civil 
population of 14,000 persons, 28 only escaped an attack. 
We may hence learn why, during the presence of an 
epidemic which proves fatal at a high per centage, the 
sum total of annual mortality is often not sensibly 
augmented. The reason is obvious. Other diseases 
fall off, and if men die of cholera, or children of small 
pox, they are not left to be the prey of pneumonia or of 
hydrocephalus, of asthma or of croup. 



34 EPIDEMIC VISITATION. 

There are some exceptions to the law that only one 
epidemic can rage at one and the same time. In 1839, 
both small pox and measles were epidemic in England 
and Wales. 

[Small pox and scarlet fever were both epidemic in New York in 
1840, '41, '42, and '43 ; and in 1840 and '41 measles was also epi- 
demic, so that the three diseases were epidemic together during the two 
last mentioned years. 

Measles and small pox were also both epidemic in Philadelphia in 
1823 and 1824; and in 1835, small pox, measles, and scarlet fever, 
were all epidemic, as was also the case in 1845. 

Measles and scarlet fever were both epidemic in Baltimore in 1837, 
and small pox and scarlet fever in 1838, and again in 1845, in that city.] 

On the succession of epidemic maladies we have as 
yet no details that can be relied on, but this branch of 
the subject invites inquiry, and promises results both 
curious and useful. We may safely leave it in the 
hands of Mr. Farr, whose laborious investigations have 
already done so much to elucidate the truth, conducted 
as they have been with great judgment, and guided by 
sound views of pathology. The notion once enter- 
tained of the recurrence of epidemics in cycles of five, 
seven, or ten years, has been disproved by modern sta- 
tistics, the cultivation of which will probably serve to 
dispel many other long-established opinions, or rather 
prejudices, in physic. 

[Epidemic diseases seem to be more fatal among the uncivilized than 
the civilized. In an epidemic of Rubeola among the Crees (a tribe of 
North American Indians) in the summer of 1846, as reported by Dr. 
Smellie {Monthly Journal of Medical Science. December, 1846), in 145 
cases treated in their camp, 40 were fatal. 

Small pox has sometimes swept off an entire tribe of Indians, as was 
the case with the Mandans (another North American tribe), and has 
been raging with great fatality among some other tribes of these Indians 
during the past and present year. 



EPIDEMIC VISITATION. 35 

Tiieee races ascribe epidemics to spells exerted by their enemies, or 
regard them as direct visitations of the Great Spirit, and abandon all 
hope of recovery as soon as attacked. 

They seem also to differ in the degree of their mortality among 
blacks, small pox, measles, and hooping cough, being more fatal to them 
than to whites, while scarlet fever would seem to be more fatal to 
whites. 

In Charleston (S. C), the mortality by small pox during the period 
from 1822 to 1848 inclusive, was 49 among the white population and 
154 among the blacks. Within the same period, 289 whites and 163 
blacks died with scarlet fever, and 45 whites and 97 blacks died with 
measles; and 100 whites and 257 blacks with hooping cough, — the 
population of the whites being 12,828, and of the blacks 17,461, in 
1830; and 13,000 whites, to 16,200 blacks, in 1840. (Census of 
Charleston, by Drs. Dawson and De Saussure. 1849.)] 

It has always been observed that epidemics are unu- 
sually severe when they first appear in any country, or 
are renewed after any long interval of time. When 
cholera first invaded India, in 1817, it raged with an 
intensity which may have been equalled, but never has 
been surpassed. When the cynanche maligna first in- 
vaded Naples, in 1618, — when small pox first appeared 
in America (1518), — when the putrid sore throat first 
invaded America in 1735, and London in 1747, — the 
ravages of each disorder were terrific. It seems, then, to 
be a law of the animal economy, that the susceptibility 
to any morbid poison is great in proportion as it has 
been little accustomed to the impression. 

[These diseases have different modifications in the same places in dif- 
ferent years, and also different modifications in different places the same 
year. 

On examination of the tables in the Appendix, it will be seen that 
during the five years from 1838 to 1842 inclusive, the proportion of 
deaths by scarlet fever to the whole mortality, was that of one to about 
thirty (29.87) in London, and one to twenty-five in New York ; while 
the proportion of deaths by the four epidemic diseases together, was that 



36 MANAGEMENT OF EXANTHEMA. 

of one to eight in London, and one to eleven in New York, during the 
same period of five years.] 

The principles which are to guide you in the general 
management of the eruptive fevers fall next to be con- 
sidered. The exanthemata cannot be cut short. Com- 
mon fever, accidentally arising, may be cut short by 
blood letting, by an emetic, or a brisk purgative ; nay, 
sometimes by the cold affusion ; but an exanthema can- 
not. It has been six, eight, or twelve days breeding. It 
must run its course. You cannot reasonably indulge 
the hope of preventing or even moderating eruption 
either on the skin or throat by active measures in the 
early stages of small pox or scarlet fever. The legiti- 
mate objects of treatment at this period are to lessen 
inordinate constitutional tumult, to subdue plethora, to 
check accidental congestions and complications. These 
are much more likely to occur when the heart and arte- 
ries are overloaded with blood, and urged to inordinate 
exertion, than when the mass of blood is in a pure and 
healthy condition. Always remember, too, when you 
bleed early in an eruptive fever, that the disease has a 
long course to run, and be moderate in your demands 
on the system. 

You perceive, then, that the great objects of treat- 
ment in these disorders, are less directed to the specific 
malady than to those congestions and superadded affec- 
tions by which the steady march of the exanthem is 
impeded. Hundreds of cases, whether of small pox, 
measles, or scarlatina, may be safely conducted to a 
close without a grain of medicine. And why 1 Because 
the febrile action or zymotic process, in such cases, goes 
on quietly, being neither too violent on the one hand, 
nor, on the other, deficient in the necessary power. To 



EXANTHEMATIC DEBILITY. 37 

give active medicine here is hurtful. It deranges 
nature. But the case is different when the febrile com- 
motion or effervescence is inordinately violent, as when 
small pox is ushered in with phrenitis, measles with 
epistaxis, scarlatina with excessive angina. Purgatives, 
leeches, cold lotions, bleeding from the arm, may then 
be required. 

On the other hand, should the vis vitse fail, should 
the first effect of the poison be to reduce the powers of 
life so low that the disorder cannot develope its regular 
and appointed series of phases, when the extremities are 
cold, the eruption tardy, when syncope occurs, or actual 
collapse threatened, then is the time arrived for stimu- 
lants, such as brandy, white wine negus, camphor, 
ether, hot bottles to the feet, mustard poultices to the 
epigastrium, and a warm bath. 

From a very early period, a notion gained ground 
that nature had provided us with substances having a 
specific power of promoting efflorescence, and warding 
off poison. They were called alexipharmics (from the 
Greek aXsgw, to repel, and yappaxw, a remedy.) At the 
head of these was saffron ; and saffron is still given to 
promote the eruption in measles, and to assist birds 
during the process of moulting. I need hardly tell you 
that this is an entire delusion. 

You will hear people talking largely of the debility 
left by the exanthemata, more especially by small pox 
and measles. This idea is not to be adopted by you 
without inquiry. It is very true that both small pox 
and measles do often exhaust the frame greatly, and by 
such debility occasion other disorders to spring up, 
which flourish only in a state of constitutional weak- 
ness and cachexia. All forms of scrofula are thus 



38 EXANTHEMATIC DEBILITY. 

developed ; but you are not to set this down as an uni- 
versal law. The truth is, not many of the exanthemata 
last long enough to induce real debility. What men 
call debility is, in nine cases out of ten, secondary fever. 
If the theory of debility be adopted, and beef tea, wine, 
bark, and tonic medicines, be administered, you feed 
the fever, and make bad worse. Not long ago, I saw 
peritoneal inflammation occasioned by acting on this 
false notion of exanthematic debility. Secondary fevers 
must be reduced, like other fevers, by purgatives, diure- 
tics, and low diet. You cannot safely stimulate in 
secondary fever. 

To no disease does this principle apply more strongly 
than to scarlet fever. I have seen this exanthem fol- 
lowed by true debility ; but febrile or apparent debility 
is far more common. The circumstances which indi- 
cate real debility in the several exanthemata will be 
mentioned hereafter. 

Much of what applies to the treatment of common 
fever applies also to the exanthemata. These points 
will be more fully detailed to you hereafter; but I may 
select two general principles as illustrative of my mean- 
ing:— 

1. One of the chief features of fever, both in a theo- 
retical and practical aspect, is the general diminution 
of secretion observable all over the body. The secre- 
tions of the mouth, the stomach, the mucous membrane 
of the intestines, the kidney, the liver, and the skin, are 
alike checked during the presence of fever. Whatever 
therefore encourages secretion aids and assists in the 
expulsion of fever. We employ, therefore, diuretics and 
diaphoretics, — calomel, with James's powder, or the 
antimonial powder, saline draughts, saline purgatives, 



INFLUENCE OF MEDICINE. 39 

jalap with cream of tartar, senna with the sulphate of 
magnesia. 

2. On the'very same principle, we avoid opiates as 
far as possible, for all opiates confine the secretions. 
Opium given to a man in health, per se, occasions a 
state of ephemeral feverishness, like wine. Opium 
locks up the bowels, diminishes the urine, causes thirst 
and a dry tongue. But it does more when the system 
is already laboring under fever of any intensity. It then 
disturbs the circulation very materially. It occasions, 
or at least aggravates, congestion in the larger vessels, 
whether in the head, chest, or belly. We often see 
opium in fever producing piles. In all exanthematous 
fevers, therefore, let opium be avoided, or administered 
with such correctives as this evil tendency of the medi- 
cine naturally suggests. 

When all is done, you will not fail to remark how 
small a proportion the strictly therapeutical and practical 
parts of the course bear to the descriptive and patholo- 
gical portions ; it will often remind you of Falstaff's 
haporth of bread to his two gallons of sack. Remem- 
ber, however, that in the exact proportion in which we 
improve the two latter, we diminish not the importance, 
but the extent, of the former. In the early periods of 
medicine, when descriptions of disease were imperfect, 
and pathology was in its infancy, and statistics were 
unknown, physicians arrogated to themselves a power 
of controlling, by drugs, the course of diseases (and 
especially of exanthematic diseases), which we now 
know to be wholly unwarranted. Pages and chapters 
were devoted to objects quite unattainable ; presenting, 
indeed, an imposing, but a vain parade of learning. In 
this respect we have improved upon our predecessors. 



40 INFLUENCE OF MEDICINE. 

We are not ashamed to acknowledge that many diseases 
must run their stated coarse, and that others will run 
their course, in defiance of all the efforts of medical skill. 
In the management of the exanthemata, be satisfied 
with steering the ship. Do not attempt to quell the 
storm. Trophilus, an ancient Greek physician, being 
asked who was the most perfect physician, replied, " He 
who knows best how to distinguish that which can 
from that which cannot be done " 



LECTURE III. 

EARLY HISTORY AND PHENOMENA OF SMALL POX. 

Pestilence of Procopius. First appearance of small pox in England and 
America. Of the sweating system. Introduction and progress of inocu- 
lation. Abandonment of that process. Of the period of incubation in 
small pox. Diagnosis of the initiatory fever. Characters of the variolous 
eruption. Maturative stage. Implication of the mucous membranes. 
Implication of the cellular membrane. Secondary fever, and its conse- 
quences. Implication of the nervous system. Of the petechial form of 
small pox. Of small pox accompanied with gangrene, ophthalmia, and 
affection of internal organs. Of the variolous pleurisy. Of the abdominal 
complications. Appearances on dissection. 

Small Pox is the most remarkable of all the eruptive 
fevers, and though I once proposed to begin with the 
simple efflorescences, and proceed thence to small pox, 
the most highly developed form of exanthematic disease, 
yet I find that other and more important objects will be 
gained by beginning with small pox. A brief sketch of 
the early history of this disease will be quite essential 
to a due understanding of the subject. 

The Greeks and Romans knew nothing of small 
pox. It is very true that Hahn in former times, and 
Dr. Willan and Dr. Baron in our own, have labored 
diligently to prove the contrary. Mr. Moore, too, has 
been no less anxious to convince us that small pox was 
known in China and Hindostan even before the time 
of Hippocrates ; but I am very incredulous on these 
points, and am borne out in this scepticism by the 
opinions of Dr. Friend, Dr. Mead, and many other 
physicians of great learning, and equally indefatigable 
in research. 



42 PESTILENCE OF PROCOPIUS. 

In the writings of Alexander Trallianus, who lived 
in the first half of the sixth century, we have a brief 
description of the whole circle of medical science as it 
existed in his days. No allusion to any complaint 
exhibiting the character of small pox is there to be met 
with. 

The first notice of a disease that looks like small pox 
is to be found in a chapter of Procopius, " De Bello 
Persico" (lib. ii. cap. 22), where he describes a dreadful 
pestilence which began at Pelusium, in Egypt, about 
the year 544, and spread in two directions, towards 
Alexandria on the one side, and Palestine on the other. 
This disease, he says, was accompanied by buboes and 
carbuncles. So far it resembled Egyptian plague ; but, 
on the other hand, Procopius distinctly states that it 
raged independent of all season ; that it spread into 
Persia and through the whole interior of Asia, and did 
not confine itself to the shores of the Mediterranean 
and Red Seas ; that it spared neither age nor sex ; that 
it affected the whole human race alike ; that it was a 
new disorder, so little understood by the physicians of 
those days, that many recovered whom they had given 
over as hopeless, and many died whom they had pro- 
nounced safe. It is stated, also, that it was peculiarly 
severe in pregnant women. All this looks very like 
small pox. 

Whether this epidemic was or was not small pox 
may be doubted ; but certainly, within a short time 
afterwards, very unequivocal traces of small pox are to 
be met with in the countries bordering on the Red Sea, 
for we read of caliphs and caliphs' daughters being 
pitted. Mr. Bruce, the celebrated Abyssinian traveller, 
wishes to fix the first epidemic of small pox to the 



FIRST APPEARANCE OF SMALL POX. 43 

era 522, which corresponds sufficiently near to the date 
of this plague described by Procopius. 

Small pox had certainly been known for several cen- 
turies before it was described. Rhazes (910) is the 
first author who mentions it : his description is clear 
and full, his theory childish in the extreme, and his 
practice very bad. Avicenna and Hali Abbas, the 
Arabian physicians who succeeded Rhazes, also men- 
tion variola, adding some facts to those already 
described. 

From the east small pox travelled to the west, 
whether slowly or quickly we have no means of ascer- 
taining. It appears to have reached England towards 
the close of the ninth century. The word variola is to 
be found in several Latin manuscripts preserved in the 
British Museum, of date decidedly prior to 900. Exor- 
cisms to ward off the dangers of this new plague are to 
be found addressed to St. Nicase. The term variola, 
the diminutive of varus, a pimple, is obviously of monk- 
ish origin. The monks,.you know, were the deposito- 
ries of all the little medical learning of those times. 
The term pock is of Saxon origin, and signifies a bag 
or pouch. The epithets small in England, and petite in 
France, were added soon after the introduction of the 
grand or great pox in 1498. 

If America (discovered in 1492) gave us, as people 
confidently say it did, the great pox, we more than 
returned the compliment by introducing to her acquaint- 
ance the small pox. This pestilence reached the 
American Continent about 1527, devastating in the 
first instance Mexico, and spreading afterwards with 
fearful virulence over the whole of that vast country. 

[" According to Humboldt, variola was introduced into Mexico in 



44 FIRST APPEARANCE OF SMALL POX. 

1520, by a negro slave ; and, from this period, it exercised its ravages 
throughout that extensive region at regular intervals of 17 or 18 years; 
and notwithstanding European vessels frequently introduced the virus 
anew subsequently, it never became epidemic except at those very 
marked intervals of time." (Forry. iV. Y. Journ. Med., March, 1844, 
p. 156.) 

Webster (Hist. JUpidemic Diseases, vol. i. p. 292) says that "in 1633 
the Indians in Massachusetts were invaded by the small pox, which 
swept them away in multitudes." 

He speaks of it as having first occurred in Boston in 1649, and sub- 
sequently in 1666, 1678, 1689, 1702, 1721, 1730, 1752, and 1764.] 

The ravages of small pox, great as they are in tempe- 
rate climates, are far greater in tropical ; severe as they 
are in the white skin, they are far severer in the black 
and colored races. 

[In the year 1752, when this disease prevailed as an epidemic in 
Boston, the mortality was about fifty per cent greater among the 
blacks than among the whites, when taken in the natural way ; and 
more than three times as great, when taken by inoculation. (Vital 
Statistics of Boston, by L. Shattuck. Amer. Jour. Med. Sci., Jan. 1841, 
p. 372.) 

The statistics of Charleston (S. C), already quoted, show the same 
fact of the greater fatality of the disease among the blacks than the 
whites.] 

Skipping over 120 years, the era at which I shall 
next pause is 1640, when the mode of treating fevers 
by the hot or sweating system had attained its acme. 
We have a splendid picture of this practice in the 
writings of Diemerbroeck, a Dutch physician and pro- 
fessor. I must treat you to some few traits of this 
system, premising that it was especially applicable to 
small pox. 

" Keep the patient," says Diemerbroeck, " in a cham- 
ber close shut. If it be winter, let the air be corrected 
by large fires. Take care that no cold gets to the 



THE SWEATING SYSTEM. 45 

patient's bed. Cover him over with blankets. Red 
blankets have always been preferred — not that the color 
is material — but because, in the times of our ancestors, 
all the best, thickest, and warmest blankets, w r ere dyed 
red. Never shift the patient's linen till after the four- 
teenth day, for fear of striking in the pock, to the irre- 
coverable ruin of the patient. Far better is it to let the 
patient bear with the stench, than to let him change his 
linen, and thus be the cause of his own death. Never- 
theless, if a change be absolutely necessary, be sure that 
he puts on the foul linen that he put off before he fell 
sick, and, above all things, take care that this supply of 
semi- clean linen be well warmed. Sudorific expulsives 
are, in the meantime, to be given plentifully, such as 
treacle, pearls, and saffron." 

This is an abbreviated sketch of the system of expel- 
ling the peccant humors in fever by perspiration ; and 
such was the condition in which Sydenham found the 
practice of medicine in 1667. He had an Augean 
stable to cleanse when he undertook the task of reform. 
Unless you have well studied the writings of physicians 
during the first half of the seventeenth century, you can 
form no just estimate of Sydenham's merits. He was 
violently attacked by his contemporaries for the system 
which he quietly substituted, but truth ultimately pre- 
vailed, and before the end of the century the new or 
cooling plan of practice was fully established. Syden- 
ham had other merits in regard to small pox. He 
described the disease admirably, and was the first who 
separated small pox from measles. 

Boerhaave, who flourished about the year 1700, was 
a devoted admirer of Sydenham. He deserves mention 
as the author who first excluded all common causes 



46 INTRODUCTION AND PROGRESS 

from the etiology of small pox, and maintained that it 
was propagated by a specific contagion or miasm alone. 
This brings us to the next great epoch — that of ino- 
culation. It was at Constantinople, about the year 1700, 
when inoculation for the small pox was first practised. 
Dr. Emanuel Timoni, Mr. Kennedy, and Dr. Pylarini, 
in 1714-15, made the profession in England acquainted 
with the discovery, but no attention was at first paid to 
it. It was reserved for a lady — Lady Mary Wortley 
Montague — to introduce this splendid improvement into 
medical practice. Her son was inoculated at Constan- 
tinople in 1717, and her daughter was reserved to be 
the first person ever inoculated in England. This event 
took place in 1721. 

[Inoculation was first advocated in this countiy by the Rev. Cotton 
Mather, and first practised, at his suggestion, by Dr. Z. Boylston, on the 
27th of June, 1721, in Boston, upon his only son, about thirteen years 
of age, and two negro servants, and was entirely successful. During 
that year and the early part of 1722, he performed it upon 247 persons 
[himself. The opposition which the introduction of the practice met, 
and which was carried so far as to endanger his life, the courage and 
energy as well as perseverance with which he carried through to final 
triumph his bold and humane undertaking, and his eventual reward in 
the amount of good accomplished, in the acknowledgments of those who 
had been his persecutors, and in pecuniary returns, are interesting mat- 
ters of historic record. (See Thacher's American Medical Biography ; 
Boston, 1828, p. 28 ; also under head of his life in same work.)] 

In the following year, after successful trials upon six 
condemned criminals in Newgate, the Princess of 
Wales submitted her own daughters, the Princess 
Amelia and Caroline, to the new process. Both passed 
through the small pox favorably. The anxiety of the 
Princess of Wales on this occasion admits of easy ex- 
planation. 

Queen Mary, wife of William the Third, died of 



OF INOCULATION. 47 

confluent small pox of the worst sort, at the age of 32, 
on the 28th December, 1694. In 1721, George the 
First had but recently come to the throne, and the direct 
succession of the Hanoverian line was of the utmost 
consequence to the court and the nation. Queen 
Mary's death had made a deep impression, which an 
interval of 25 years had not banished from the recollec- 
tions of the people. Hence doubtless arose the ex- 
treme anxiety of the Princess of Wales to fly to the 
novel expedient of inoculation. 

The first ten years of its career were singularly 
unfortunate. It fell into bad hands. It was tried on 
the worst possible subjects, and practised in the most 
injudicious manner. The consequence was, that it 
soon fell into disrepute. The pulpit, too, sounded the 
alarm, and in truth, conducted as inoculation then was, 
it was a very questionable improvement. 

A new era arises in 1746, when, the practice being 
better understood and appreciated, the Small Pox Hos- 
pital was founded, to enable the poor to participate in a 
benefit hitherto confined to the rich. In 1754, the 
College of Physicians put forth a strong recommenda- 
tion of inoculation. About the same period, Mead and 
De la Condamine wrote treatises in favor of it, the 
former in London, the latter in Paris. At length, in 
1763, the practice was undertaken by an exceedingly 
clever man, Mr. Robert Sutton, who, with his two sons, 
inoculated with admirable skill and wonderful success. 
In 1775, a dispensary was opened in London for the 
gratuitous inoculation of the poor at their own houses ; 
but the institution failed, chiefly through the opposition 
of Baron Dimsdale. The Small Pox Hospital then 
took up the plan of promiscuous inoculation, which 



48 DEFINITION OF SMALL POX. 

was carried on to an immense extent between the 
years 1790 and 1800. 

In 1798, Dr. Jenner announced the discovery of 
vaccination. On the 5th of May, 1808, the inoculation 
of out-patients was discontinued at the Small Pox Hos- 
pital. On the 20th June, 1822, inoculation was discon- 
tinued to in-patients. On the 23d July, 1840, the 
practice of inoculation, the introduction of which has 
conferred immortality on the name of Lady Mary W. 
Montague, which had been sanctioned by the College 
of Physicians, which had saved the lives of many kings, 
queens, and princes, and of thousands of their subjects, 
during the greater part of the preceding century, was 
declared illegal by the English parliament, and all 
offenders were to be sent to prison, with a good chance 
of the treadmill. It is even provided that an attempt to 
produce small pox by inoculation, even though unsuc- 
cessful (including, of course, the testing of vaccinated 
subjects at all ages), is an offence at law ! Such are 
the reverses of fortune to which all sublunary things are 
doomed. 

We define small pox to be a disease, the product of 
a morbid poison or miasm, which, after a certain period 
of latency, developes eruption on the surface, passing 
through the stages of pimple, vesicle, pustule, and scab, 
with certain other concomitant or succeeding affections, 
which runs a stated course, and having exhausted itself, 
removes from the constitution the susceptibility of a like 
attack. 

Small pox is divisible into varieties. The terms 
confluent and distinct express two of the most remark- 
able, but others are equally important. I shall speak 



PERIOD OF INCUBATION. 49 

to you here of confluent, semi-confluent, corymbose, 
distinct, and modified small pox — of superficial, cellu- 
lar, and tracheal small pox — of the benignant, malig- 
nant, and petechial small pox — of simple and compli- 
cated small pox. 

Every kind and variety of small pox is divisible into 
three stages — incubation, maturation, and decline. 

1. Of the period of incubation. This is the latent 
or dormant period of some authors, and it includes the 
whole period that elapses from the reception of the 
variolous germ to the development of eruption. The 
first few days are passed, in many instances, without 
symptoms of any kind, but in other cases there are 
obvious evidences of some morbid process going for- 
ward. At the moment of receiving the miasm, the 
patient experiences, perhaps, an unpleasant odor, or a 
feeling of sickness, or of giddiness, or of inward alarm. 
As the incubation advances, his nights are restless, his 
spirits low. He is oppressed with languor and lassi- 
tude. With respect to the period of incubation, a large 
accumulation of facts enables me to fix it at twelve 
days of apyrexia and two of fever — fourteen in all. 
One example may suffice. 

Mrs. Joseph, wife of Mr. Joseph, surgeon, of Great 
Marylebone street, registrar of births and deaths for the 
Kectory district of Marylebone, was sitting in her parlor 
on Monday, June 7, 1841, when a nurse called to 
register the death of a child who had died the preced- 
ing day of small pox. The nurse had just left the 
dead body. Mrs. Joseph's suspicions were sufficiently 
excited to induce her to have her baby vaccinated 
immediately, but she never thought of herself. On 
Saturday, June .19 (thirteenth day from exposure to 

4 



50 CHARACTER OF ERUPTIVE FEVER. 

the miasm), Mrs. Joseph sickened. On Monday, June 
21 (being that day fortnight on which the child's death 
had been registered), small pox appeared in her. 

The incubative period admits of some latitude. The 
extremes may perhaps be stated at ten and sixteen 
days. 

With regard to the initiatory or eruptive fever (con- 
stituting the last two days of the incubative period), it 
may be remarked, that on the twelfth or thirteenth day 
from imbibing the germ, rigors occur, followed by the 
usual evidences of pyrexia — a quickened pulse, heat of 
skin, pains of the back and limbs, scanty and high- 
colored urine, and restlessness. How can you prognos- 
ticate that the fever then breeding is variolous ? 

(1.) By the sickness at stomach. This is often very 
intense, continuing for two or more days, and often 
accompanied by tenderness of the epigastrium on pres- 
sure. There is irritability of the stomach here, but not 
inflammation, for the vomiting is uninfluenced by 
bleeding, and yields when the eruption shows itself. 

[Heberden says, " if the vomiting be continued after the eruption is 
completed, the patient's life is in great danger, even though the small 
pox be not confluent." — Commentaries, p. 355.] 

(2.) By the pain of the back and loins. This, too, 
is often very intense, so that men carrying a load have 
dropped down in the street. The most remarkable 
case of the kind which I ever saw was the following : 
— Mrs. Delahay (Little Marylebone Street), at the full 
time of her first confinement, began to complain, No- 
vember 23, 1837. The pain of the back was very 
severe, with very little intermission. Yet the os uteri 
scarcely dilated at all. Mr. Jordan, who attended her, 
seeing some peculiarity in the case, requested my assist- 



CHARACTER OF ERUPTIVE FEVER. 51 

ance. The pain of the back was agonizing, and she 
continued to suffer from it during the whole of the 23d, 
the os uteri continuing unaltered. She was put into 
the warm bath, took 200 drops of laudanum, and was 
bled to thirty ounces. At one a.m. on the morning of 
the 24th, she was delivered of a dead child, but pain 
still continued. On the evening of the same day, con- 
fluent small pox appeared, when the pain of the back 
ceased. She had been well vaccinated in early life. 

The peculiarity of this case consisted, you will per- 
ceive, in the incubative stage of small pox concurring 
with the completion of utero-gestation. The infant's 
life was destroyed by the intensity of the fever. 

[Lumbar pain is one of the most common precursory symptoms of 
variola, and often of a great degree of severity, and is not met with in 
either scarlatina or rubeola, or at least to an amount at all marked, and 
its presence often assists materially in the diagnosis of this disease. 
Heberden says, " an excruciating pain in the loins has never failed to 
be succeeded by a bad small pox, and the more violent the pain, the 
greater has been the danger ; it is much safer to have it between the 
shoulders." — [Commentaries, p. 354.) I have, however, seen a mild 
attack of varioloid follow severe pain in the back, and the reverse of 
this is also true.] 

(3.) Encephalic symptoms accompany the initiatory 
fever of small pox in certain cases. Adults complain 
of severe headache. There is stupor or delirium. The 
face is flushed. The carotid and temporal arteries 
beat strongly. The patient is supposed to be on the 
eve of a severe cerebral affection. Somnolency or an 
epileptic fit is often noticed in children. 

(4.) Syncope and excessive prostration of strength 
are the leading features in some cases. I have seen 
syncope occur on the seventh day after inoculation. 
Occasionally, even in strong habits, the effect of the 



52 DURATION OF ERUPTIVE FEVER. 

miasm is so thoroughly poisonous that the countenance 
turns pale, the pulse is feeble, the extremities become 
cold. The patient is brought into a state of collapse. 

(5.) Great anxiety of the prsecordia, deep sighing, 
and dyspnoea (symptoms indicating thoracic conges- 
tion), are occasionally noticed. 

[" A great shortness of breath coming on about the fifth day of the 
eruption, scarcely leaves any hopes that the patient will survive." — 
Heberden — Commentaries, p. 35 7.] 

Sometimes the one, sometimes the other of these 
groups of symptoms predominates during the brief 
period of eruptive fever. In addition to the evidence 
which they afford, the suddenness of the seizure, the 
previous good health of the patient, the circumstance of 
prior exposure to the contagion, or having previously 
undergone small pox, will assist in the diagnosis. In 
adults, the fact of prior vaccination is not to throw you 
off your guard, for the initiatory fever is just as severe 
after vaccination as it is in the unprotected. 

The eruptive fever of small pox acknowledges the 
tertian type. Forty-eight hours elapse from the rigor 
to the first appearance of eruption. Sydenham believed 
that the more time nature occupied in finishing the 
separation of the inflamed particles, the greater was the 
chance of ultimate safety to the patient; and accord- 
ingly he never interfered at this period. Before his 
time, the theory and practice were different. It was 
thought that nature was struggling to effect the separa- 
tion, that she required assistance to do this effectually, 
which assistance was afforded to her in the shape of 
heating diaphoretics and alexipharmics. 

The duration of the eruptive fever is never less than 
forty-eight hours. It may be protracted, by weakness 



CHARACTER OF THE ERUPTION. 53 

of habit, to seventy-two hours, and the full development 
of eruption over the whole surface may even occupy 
three complete days. Minute papulae sensibly elevated 
above the surface of the skin show themselves, in the 
first instance, on the face, forehead, and wrists. In a 
few instances only does the eruption commence on the 
lower extremities. It often happens that two or three 
large papulae precede the general eruption, and advance 
to the state of vesicle, before the surface is extensively 
occupied. 

[The first pustules are usually seen on the upper lip, cheeks, and 
forehead, but they are often found on the velum palati sooner than on 
any other part. Hence it is always important to examine the inside of 
the mouth and the throat, when this disease is suspected, to aid in the 
diagnosis. Sometimes the parts are inflamed without any perceptible 
eruption; at other times, both inflammation and papulae can be 
plainly seen.] 

In a large proportion of cases, the outbreak of erup- 
tion affords great relief to the general constitutional dis- 
turbance. The fever moderates, the sickness abates, 
the dorsal pains diminish, the head is relieved. From 
all this, you will perceive that such symptoms depend, 
not on inflammation, but on vas ular distension. 

Something may be learned by attention to the 
arrangement of the papulae. They are not thrown 
together confusedly and without order, but are arranged 
in groups of three or five. Crescents and circles may 
be traced very distinctly when the eruption is not too 
copious. This constitutes an important diagnostic 
between variola and varicella. 

The external character and internal structure of the 
variolous pimple and pustule have excited much atten- 
tion. Cotuguo, in Italy, commenced the investigation, 



54 ORGANIZATION OF THE PUSTULE. 

which John Hunter, Dr. Adams, and, in more recent 
times, Bousquet, Gendrin, Mr. Judd, Dr. Petzholdt, and 
others have continued. 

[To the names quoted by our author of those who have investigated 
the structure of the small pox pustule, may be added that of Dr. Simon, 
who has given a minute description of its peculiarities in his work on 
diseases of the skin, a full abstract of which may be found in the Brit, 
and For. Med. Chir. Rev., April, 1849, p. 349.] 

The organization of the variolous pustule is very 
curious. Inflammation begins at a spot called the 
phlyctidium. Its seat is in the cutis vera. From the 
central point, or stigma, the inflammatory action pro- 
ceeds by radiation on the surface, penetrating to a 
greater or less depth in different cases. Beneath the 
epidermis, and constituting the greater part of the 
phlyctidium, is found a substance, or disc, of the con- 
sistence of pulp or thick mucus. This is not considered 
as any part of the skin altered by disease, but as the 
product of a specific action of the vessels. John Hunter 
and Adams called it the variolous slough. At the 
height of suppuration this substance is swollen, and 
moist like a sponge. The floor of each phlyctidium 
presents the papillated structure of the skin, elevated, 
and marked with fissures. The vesicle is divided, like 
the substance of an orange or poppy-head, into nume- 
rous cells (twelve, or more). It is, as we say, multilo- 
cular. A filament of cellular tissue binds down the 
central portions of cuticle to the lower surface of the 
phlyctidium, and gives to the vesicle, in its early stages, 
that umbilicated form, that depression of its centre, 
which, though not peculiar to the variolous eruption, is 
so important as a diagnostic mark between it and genu- 
ine varicella. The fluids (lymph and pus) which at 



MATURATIVE STAGE. 55 

different periods distend its cells, destroy at length the 
filamentous attachment of the stigma to the cuticle, and 
that which was at first a depressed or umbilicated vesi- 
cle, becomes at last an acuminated pustule. It bursts, 
discharging a well formed purulent matter, of a yellow- 
ish color and creamy consistence. 

2. The inflammation of the phlyctidium is accompa- 
nied by a kind of erythema, or specific inflammation, 
called the areola, extending to some distance beyond 
the margin of the vesicle. The color of the areola is 
always to be carefully noted, for reasons which will 
soon be explained. On the subsidence of this inflam- 
matory areola, the ripened pustules, having burst and 
discharged their contents, are succeeded by scabs, which 
dry up, and, in a healthy state of constitution, fall ofT in 
four or five days. In mild cases, where the full process 
of pustulation is not gone through, many of the vesicles 
shrivel, and form only tubercles, or imperfect scaly 
crusts. On the lower extremities, this premature desic- 
cation of the vesicles is often very general. 

In severe cases, the inflammation of the corion does 
not cease with the completion of the pustulating process. 
Portions of the cutis vera are then actually destroyed 
and slough away, the result being that, when cicatriza- 
tion is at length completed, the skin presents the ap- 
pearance of pits or foveae, with a diffused clarety hue of 
the surface. This tint wears off in the course of three 
or four months ; but the depressions are permanent. 
From the great vascularity of the face, there is always 
most risk of such disfigurement there. 

Nurses will talk to you of a five, six, seven, eight, 
nine, and even ten days' pock. They are quite right. 
When the disorder is perfectly normal in its course, not 



56 



MATURATIVE STAGE. 



interfered with by any peculiarity of habit either con- 
genite or acquired by previous vaccination, — when the 
constitution is sound, with sufficient strength of system, 
and a good, but not over-abundant supply of blood, — 
lastly, when there is not too copious a crop on the sur- 
face, the pock maturates in seven days. In severe cases 
of a semi-confluent or corymbose kind, the process of 
maturation occupies eight days. In bad confluent 
cases, nine or perhaps ten. On the other hand, after 
vaccination, or when there is some originally favorable 
diathesis present, the pock will maturate in six, or some- 
times imperfectly in five days. This five-day pock 
constitutes the mild, mitigated, or modified form of 
variola, now so familiar to us, as occurring in those who 
in early life had been well vaccinated. But this variety 
of the disease, though formerly less frequent, was yet 
well known to all the old authors. Van Swieten 
describes it under the title of variola verrucosa and 
cornea (stone pock, horn pock, and wart pock). 

A certain amount of fever accompanies the matura- 
tion of the pock even in its mildest aspects. The actual 
amount depends mainly on the quantity of eruption, but 
something is attributable to the habit of the patient, 
whether irritable or otherwise. A quiet condition of 
mind is always favorable to small pox. Something de- 
pends, too, upon season, something on diet, and the 
temperature of the room in which the patient lives. 
The corymbose, or partially confluent form of small 
pox (where the vesicles are grouped into clusters, leav- 
ing intermediate spaces of unoccupied skin), is always 
attended with severe and irregular fever. 

The maturative process is often accompanied by an 
exceedingly tender state of the surface. This happens 



IMPLICATION OF THE MUCOUS MEMBRANE. 57 

chiefly in women, and in men of delicate skin. It is a 
very favorable sign, though productive of much tempo- 
rary inconvenience. The variolous matter, when 
abundant, gives off a peculiar, faint, and sickly odor. 
Recovery may be retarded, even in the distinct small 
pox, by weakness of habit, by cold, and the excitation 
of scrofulous disease. Ecthymatous eruption may then 
occupy the surface ; the skin may be left dry and scaly ; 
the scabs may be adherent. All this is owing to the 
setting up of a low form of secondary fever. 

I must next draw your attention to the implication 
of certain of the mucous structures in the progress of 
small pox. In a large proportion of confluent, and in 
some semi-confluent cases, the mucous membrane of all 
those parts to which the atmospheric air gets access 
(the nose, mouth, and trachea), is occupied with erup- 
tion — sometimes distinct, more generally confluent. 
The early symptoms occasioned by this mucous com- 
plication are as follows : — Numerous white points appear 
on the tongue, palate, and velum pendulum. Hoarse- 
ness and alteration of voice indicate that the same con- 
dition extends to the mucous membrane of the larynx 
and trachea. There is great pain in swallowing, and 
in bad cases cough and dyspnoea. The cough is at 
first dry and tearing. As the disease progresses, there 
is expectoration. About the eighth day, a copious 
viscid secretion takes place from all the affected struc- 
tures. 

The ulterior effects of this mucous implication are 
far more important than any local mischief which it 
occasions. The cedematous thickening of the larynx 
and the swollen condition of the tracheal membrane, 
have by the eighth day materially impeded the free 



58 IMPLICATION OF THE MUCOUS MEMBRANE. 

access of air to the lungs, and the consequences appear 
in every part of the circulating system. There is no 
crimson areola, for the blood is not well arterialized. 
The vesicles on the extremities never acquire any 
inflammatory areola, by which alone the surface can 
be cicatrized. On the trunk the areola is dark or 
claret-colored. The vesicles do not acuminate. They 
lie flat, and present much of the same appearance which 
is displayed after death. Sometimes the superficial 
inflammation partakes more of an erysipelatous than of 
a phlegmonous character. The results are large watery 
blebs, from which flows out a thin ichor. Consequences 
still more serious happen in the succeeding twenty-four 
hours. The brain becomes affected. A low muttering 
delirium is observed, as the waves of ill oxygenated 
blood begin to circulate. The tongue swells and exhi- 
bits a purple hue. Restlessness and great anxiety suc- 
ceed. The patient tries to get out of bed. The 
bladder loses its contractile power, and may be felt dis- 
tended at the brim of the pelvis. The extremities 
become cold. Dyspnoea increases, and the patient 
dies ! 

[According to M. Louis, fifteen twentieths of all that die of variola, 
perish from asphyxia consequent upon affections of the larynx and air 
passages generally. 

For an interesting paper on this subject, with cases confirmatory of 
this remark, by Charles R. King, M. D., see N. Y. Journ. of Med. and 
Surgery, April, 1840, p. 269. 

The present state of our knowledge respecting oedema glottidis, sug- 
gests the inquiry, whether this state of the parts in variola may not be 
the cause of the sudden fatality of a certain number of cases, and if this 
be the case, whether the operation proposed for its relief by Dr. G. 
Buck of this city, might not be practised with benefit. For an account 
of this operation, with illustrative plates, vsee Trans. Amer.Med. Asso- 
ciation, vol. i. p. 135.] 



CONSEQUENCES OF SECONDARY FEVER. 59 

The implication of the cellular membrane in the 
progress of small pox must next engage our attention. 
In the distinct small pox the skin continues movable on 
the subjacent textures, but in all bad cases, confluent, 
semi-confluent, and corymbose, the inflammatory action 
dips deeper, and invades the cellular membrane. The 
skin now becomes swollen and tense. This cellular 
complication is sometimes universal, sometimes partial. 
The scalp is very often affected. Enormous intumes- 
cence takes place, followed by diffuse pustulation, or a 
succession of small and most troublesome abscesses. The 
cellular membrane of the throat is peculiarly liable to 
take on this action. The salivary glands participate in 
the inflammation, and salivation with great turgescence 
of the neck follows. Occasionally the tongue becomes 
involved. Glossitis is superadded to other evils, and 
few, if any, survive, when matters have proceeded to 
this extremity. Supposing, however, that neither the 
cellular nor laryngeal inflammation is in sufficient 
intensity, on the eighth or ninth day, to destroy the 
patient, then secondary fever sets in, to be known at all 
times by the occurrence of rigors, followed by a hot and 
dry state of the surface, and a thirst unquenchable. * 

3. In the progress of secondary fever you must be 
prepared for all sorts of troubles. The skin, already 
weakened and prone to inflammation, is sure to suffer 
first. The elbows, legs, scrotum, knees, back, and hips, 
take on a mixed erysipelatous and phlegmonous action. 
The result is either boils and abscesses, or enormous 
imposthumes, or carbuncles, and gangrenous destruction 
of large portions of the skin, according to the severity of 
each case. On the 17th July, 1829, 1 saw at the Small 
Pox Hospital an exact counterpart of the pestilential 



60 MODIFIED VARIOLA. 

bubo and carbuncle on the groin of a small pox patient 
Sometimes the whole surface of the body is covered with 
a vivid scarlatinal rash. The face always suffers severely 
in this aggravated form of cellular small pox, and the 
patient (if happily he escapes) passes through a tedious 
process of convalescence. In 1828 I saw a woman 
whose face was not simply pitted, but scored and seamed, 
She informed me that she was twelve years in recovering, 
and I could well believe it. The disposition in inflamed 
parts, during the secondary fever of small pox, to termi- 
nate in suppuration, appears to be universal, and almost 
uncontrollable. In some few cases the larger joints fill 
with purulent matter. 

Confluent and semi-confluent cases of small pox, 
though very frequently, are not necessarily accompanied 
with cellular complication. There is a form of the dis- 
ease called the confluent superficial, where the eruption 
passes through all its regular stages, but the inflamma- 
tory action never extends beyond the outer layer of the 
corion. This is sometimes confounded with the modi- 
fied small pox, but the progress of eruption is very 
different in the two cases. The confluent superficial 
small pox appears in the unvaccinated. The pustules 
maturate equally and regularly. The confluent modified 
small pox, on the other hand, never appears except in 
the vaccinated, and the advance of the pustules is not 
only imperfect, but it is unequal on the same portion of 
surface. On the arm, for instance, at one and the same 
time, you will perceive some pustules fully maturated, 
others of smaller size desiccating after the escape of a 
minute portion of pus, while part of the eruption has 
become tuberculated without purulent formation, and 
with little or no surrounding inflammation. This ine- 



IMPLICATION OF THE NERVOUS SYSTEM. 61 

quality of aspect is the great characteristic of modified 
variola. 

I must next draw jour attention to the implication of 
the brain and nervous system in the phenomena of small 
pox. Children grind their teeth, and squint. Cerebral 
inflammation supervenes and the child dies, either in an 
epileptic fit, or with evident signs of hydrocephalus. 
Adults become delirious, and occasionally it is of that 
severe kind called delirium ferox, accompanied with 
great wildness of the eye, and such strong tendency to 
self-destruction that the utmost precautions do not over- 
step the necessities of the case. Variolous delirium 
depends more on some peculiarity of temperament, on 
some highly irritable condition of the nervous system, 
than it does on inflammation. Thomas Weston became 
a patient of the Small Pox Hospital on the 17th of July, 
1829. For several years his thoughts had been absorbed 
in religious matters. He would often say that he was 
better prepared to die then than he could be if his life 
were lengthened. When it was announced to him that 
his complaint was small pox, he expressed no wish to 
recover. The eruption was moderate in quantity — not, 
per se, threatening danger. He had been vaccinated in 
early life. Delirium set in early, and he died on the 
eighth day of the disease. A peculiar nervous affection 
often supervenes on the tenth day, when the skin is 
extensively occupied by the confluent eruption without 
nervous complication. It is identical with that which 
is familiar to surgeons as the consequence of extensive 
burns and scalds. General tremors, low delirium, a 
quick and tremulous pulse, a dry tongue, collapse of the 
features, cold extremities, and subsultus tendinum, are 



62 PETECHIAL SMALL POX. 

the symptoms of this nervous complication, and the pre- 
cursors of a fatal event. 

The implication of the Jiuids next demands notice. 
It happens occasionally, though happily not often, that 
the miasm of small pox poisons the blood, alters its 
crasis or coagulating properties, and leads to haemor- 
rhages from every open surface. The evidences of this 
condition of the fluids are often perceptible from the 
first hour of initiatory fever. At other times they are 
not noticed until the eruption has begun to develope 
itself, or even later in the maturative stage. The erup- 
tion has a livid or dingy aspect. The expression of the 
countenance is highly anxious. If blood be drawn from 
the arm, a loose layer of fibrine is thrown up, beneath 
which you find fluid red blood. Haemorrhage takes 
place from the nose, mouth, lungs, stomach, bowels, and 
kidney. Petechias and patches of ecchymosis (called 
vibices) appear intermixed with the variolous papulae. 
The variolous vesicles fill with blood, instead of serum. 
The aspect of body in some cases of aggravated pete- 
chial small pox is wholly changed. 

In February, 1842, 1 saw, in consultation with Dr. L. 
Stewart, a lady in small pox, whose whole body was of 
the color of indigo, and whom I at first believed to be a 
native of Africa. She conversed with me in the most 
tranquil manner, and died a few hours afterwards, 
proving that the nervous system is not necessarily, nor 
is it even usually, implicated in the petechial form of 
small pox. 

When adult females are thus attacked, menorrhagia 
is almost always observed, and if they be pregnant, 
abortion or premature delivery takes place. The foetus, 
as you might naturally expect, dies in utero. 



PETECHIAL SMALL POX GANGRENE. 63 

[Heberden says (Commentaries, p. 355) that in the worst cases of 
small pox, the menstrual discharge has come on out of its regular course 
two days before the small pox has begun to show itself, and has con- 
tinued to flow in an excessive manner, and that it has sometimes 
appeared before its regular time, together with the eruption ; but that 
more commonly it has begun as soon as the eruption was completed, 
and continued from one day to five. The discharge does not check the 
progress of the small pox, nor depress the patient's strength, and 
requires no interference from art. The prognosis, however, is entirely 
different, and of a very serious character, when there is a complication 
with purpura, attended with haemorrhages from other parts. Such cases 
are almost always fatal. 

The period at which miscarriage takes place is usually at the time of 
suppuration of the pustules, which is about the seventh or eighth day 
from the first eruption, a day or two after which death more commonly 
occurs. A case, however, is related by Dr. Marrotte (Gaz. des Hopitaux, 
Sept. 5, 1846), in a woman 26 years old, who aborted in the fourth 
month, five days after the complete desiccation of the variolous pustules, 
and without any external cause. The foetus presented no trace of erup- 
tion, which is most usually the case. A small proportion pass through 
the disease without miscarrying.] 

This variety of small pox was known of old by the 
name of the black pox (variolar nigrse), and appears to 
have been more frequent in former times than it is now. 
Death may take place in consequence of this remarkable 
condition of the blood before any unequivocal signs of 
small pox are developed. More commonly, the erup- 
tion, confluent in character, displays itself, but never 
makes much advance. Nature apparently gives up the 
struggle as hopeless. The patient is carried off very 
unexpectedly, perhaps on the fourth, or from that to the 
sixth day. 

There is something not very well understood in the 
concurrence of gangrene with small pox. It is not 
necessarily connected with the petechial state, nor with 
affection of the nervous system, nor with debility. It 



64 OPHTHALMIA. 

often occurs where the fever is of a truly inflammatory 
type, and where no previous symptom gave evidence of 
unusual danger. It is more generally found attendant 
on the irregular or corymbose small pox than on the 
purely confluent cases. The chief seats of variolous 
gangrene are the scrotum, feet and back, but I have 
seen it also on the breast. 1 cannot doubt but that in 
certain cases the gangrenous disposition is something 
superadded to the small pox by the condition of the air 
which the patient breathes. 

Small pox is often accompanied with ophthalmia. It 
has been stated that this arises from the formation of 
pustules on the cornea and conjunctival membrane. 
This is erroneous. If these structures had been sus- 
ceptible of the specific variolous eruption, every con- 
fluent case must necessarily have ended in total blind- 
ness ; but, happily, Nature has arranged it otherwise. 
Conjunctival inflammation, iritis, inflammation still 
deeper seated, may indeed arise, especially when exten- 
sive crusts put a stop to all perspiration, and when 
secondary fever rages in the blood, and devastates 
internal organs. But there is no specific inflammation 
of the eye in small pox. 

The ophthalmia by which so many eyes have been 
lost is a sequela of the disease, generally coincident 
with some great destruction of surface in a distant part. 
In some cases, variolous ophthalmia, setting in on the 
tenth day of the disease, advances so rapidly, that in 
forty-eight hours the whole eyeball is irremediably 
injured, I have seen the whole eye converted into 
one large abscess. More usually, the inflammation runs 
into some of its less violent and more familiar conse- 
quences. An ulcer forms at the outer edge of the cor- 



AFFECTIONS OF INTERNAL ORGANS. 65 

nea, by which the aqueous humor escapes, or at which 
staphvlomatous protrusion of the iris takes place ; or 
the aqueous humor becomes clouded, or specks form on 
the cornea, from which blindness more or less com- 
plete, more or less permanent, results. 

Although, at present, we are not in a position to 
affirm it positively, yet many facts concur to render it 
almost certain, that this secondary affection of the eye 
in small pox is connected with and dependent upon 
some altered condition of the blood — certain matters 
being retained within it which ought to have been 
eliminated. 

It would be unreasonable to believe that such a fever 
as I have described should rage, expend its whole viru- 
lence on the skin, and never affect the great internal 
organs of the chest and abdomen. Bronchial inflam- 
mation is sometimes present during the whole course of 
the complaint, especially in the winter season, but it 
does not materially complicate the phenomena. In 
Lascars, and all natives of tropical climates, attacked 
by small pox in a cold climate, this frequently happens, 
and may of itself prove the cause of death. Sometimes, 
even among our own people, the substance of the lungs 
becomes involved in inflammation, and its usual conse- 
quences. But the great peculiarity deserving of your 
notice is the frequency of variolous pleurisy. It occurs 
between the twelfth and twentieth day. It is a pera- 
cute form of inflammation, remarkable for its sudden 
invasion, rapid progress, and invariable termination by 
empyema. The symptoms are very unequivocal. 
Intense pain, a hard, wiry, and incompressible pulse, 
shortness of breathing, and a dry state of the surface, 

5 



66 APPEARANCES ON DISSECTION. 

betoken but too forcibly the state of the pleura. Blood- 
letting is almost powerless in this disease. Death usu- 
ally happens on the third, or, at furthest, on the fourth 
day, from the invasion of thoracic symptoms. The 
heart occasionally becomes involved. Syncope, palpi- 
tation, and a sense of exhaustion, are the evidences of 
this complication. I have seen such symptoms con- 
current with phlegmasia dolens of the leg, indicating an 
inflammatory condition of the blood-vessels. These 
cases prove fatal very rapidly. 

Small pox is singularly exempt from all abdominal 
complication. Children sometimes fall into a state of 
mucous enteritis, with frequent, slimy motions, and 
emaciation ; but nothing occurs here to warrant me in 
detaining you. 

The appearances, on dissection, peculiar to small 
pox, are confined to those which the larynx and tra- 
chea exhibit. The lungs, indeed, sometimes display 
the usual evidences of inflammation — vascular engorge- 
ment, purulent infiltration, and hepatization. The 
thorax of one side may be found replete with a sero- 
purulent fluid (resembling a mixture of cream and 
water), the result of acute pleurisy, and the pleura itself 
may be seen injected with blood, and covered with a 
dense layer of coagulable lymph ; but all this occurs 
equally in other diseases. The condition of the larynx 
and trachea, however, in small pox, on the eighth day, 
is unique. The mucous membrane, if then inspected, 
appears covered with a copious, viscid, puriform secre- 
tion, of a grey or brownish color. On detaching this, 
the membrane itself is seen deeply congested with 
blood, thickened, pulpy, and, in the worst cases, black 



APPEARANCES ON DISSECTION. 67 

and sloughy, exhaling a most offensive odor. These 
appearances may be traced to the third division of the 
bronchial tabes. 

Much discussion has taken place regarding the 
occurrence of variolous pustules on the gastro-enteric 
mucous membrane. Cotuguo, Wrisberg, iteil, and 
others, who have paid great attention to the subject, 
concur in opinion that this structure is not capable of 
developing them. Sir Gilbert Blane, again, reports a 
case where the mucous membrane of the bowels pre- 
sented the appearance of ulcerated spots, which he 
compared to variolous pustules. The experience of 
the Small Pox Hospital is in favor of the old doctrine. 
Inflamed, enlarged, aud ulcerated follicles, with pete- 
chial patches, may indeed be noticed in a few rare 
cases ; but such appearances are in all respects the 
same with those observable in typhoid fever, 

[Pathologists seem to be divided in opinion as to the existence of 
true variolous pustules on the mucous membrane of the intestinal canal, 
Louis. Gerhard, MM. Barthez and Rilliei, Petzholdt, and Chapman, 
uniting with those mentioned by our author in denying that thev are 
ever present there, and saying that a follicular eruption, not unfrequently 
found both at the beginning and end of the small intestine, and more 
rarely in the large intestine, has given rise to the error. 

Dr. George Patterson, however, of Edinburgh, lately reported a case 
of a boy, five years old, in which pustules and superficial incrustations 
were found in the lower part of the intestines, and the statement is 
corroborated by Dr. TT. T. Gairdner, who made the post-mortem exami- 
nation with Dr. Patterson. The whole case was so well characterized, 
that he considered it as an unequivocal instance of varioloid eruption in 
the colon. 

M. Rostan is also quoted as authority in favor of their having been 
found throughout the whole intestinal tract.] 

In like manner, the brain presents, in small pox, no 
morbid phenomena different from those which other 
types of fever display. 



LECTURE IV. 

STATISTICS AND PATHOLOGY OF SMALL POX. 

Diagnosis of small pox. Statistics of small pox. Mortality by small pox 
in the la?t century, and throughout England and Wales, since 1837. 
Proportion of mild to severe and fatal cases. Periods of the disease at 
which death takes place. Direct causes of death in small pox. Patho- 
logy of small pox. Question of spontaneous origin. Of miasmatic 
origin exclusively. Circumstances that determine the character of the 
disease. Epidemic diffusion of small pox. Laws by which it is governed. 
Susceptibility of small pox. Of recurrent or secondary small pox. Case 
of Louis XV. Communication of small pox to the foetus in utero. 

In the present lecture I propose to bring before yon, in 
one view, the several considerations which reflection on 
the phenomena of small pox is calculated to elicit. 
Everything that relates to diagnosis, statistics, and the 
origin of the disorder, comes therefore now to be inves- 
tigated. To distinguish one disease, however, from 
another, it is obviously requisite that the course of both 
should be known. We are therefore hardly in a situa- 
tion yet to enter with advantage on this topic of inquiry. 
Nevertheless, that nothing may be omitted which can 
contribute to your practical benefit, I will say a few 
words on the diagnosis of small pox. 

The diseases with which, after the occurrence of 
eruptive fever, small pox may be confounded, are 
measles, febrile lichen, varicella, and secondary syphilis. 

J. The papulae of small pox are firmer than those of 
measles. They feel granular under the finger. In 
measles, too, there are accompanying cough and watering 
of the eyes. Further, in small pox, forty-eight hours 
elapse from rigor to eruption ; in measles, seventy-two. 



DIAGNOSIS OF SMALL POX. 69 

2. Febrile lichen is the disease from which small 
pox, at its onset, is with most difficulty distinguished. 
The aspect of eruption is in both cases nearly alike. 
The surest and safest grounds of diagnosis are based on 
the interval which has elapsed from rigor to eruption, 
and the mode in which the eruption has developed 
itself. In febrile lichen, twenty-four hours elapse from 
sickening to eruption ; in small pox, as you know, 
forty-eight. Small pox almost always appears first on 
the face. The eruption of lichen is developed, from the 
first, uniformly over the head and trunk. Besides 
which, your judgment will be materially aided by 
inquiries into the prior history of the patient, and the 
character and course of incubation. 

[Id febrile lichen, the gastric derangement would probably be greater, 
although without vomiting, there would be no pain in the back, and 
the itching would be so marked as to form a prominent symptom. 
The early appearance of pustules on the velum and palatine arches has 
also assisted me in the diagnosis. At the same time I would add, that 
this form of lichen, presenting such a resemblance to small pox as to 
give rise to uncertainty in the diagnosis between the two diseases, has 
seldom come under my observation, and cannot be of very frequent 
occurrence amongst us.] 

3. The diagnosis of small pox and chicken pox 
requires attention to minutiae, and cannot be given until 
a later period of the course, when the phenomena of 
that mild disorder will be duly submitted to you. 

4. There is a form of secondary syphilis, in which 
an eruption appears on the face and trunk very similar 
to the distinct small pox. This syphilitic eruption 
passes through the several grades of papula, vesicle, and 
pustule. It is preceded by a febrile attack of variable 
duration. The diagnosis is to be effected by careful 
inquiry into the whole history of the case, and close 



70 STATISTICS OF SMALL POX. 

observation of the progress of the disease. To those 
accustomed to the look of small pox, there is something 
in the general aspect of a syphilitic patient, in the 
absence of all febrile anxiety, which would at once 
indicate that the generating miasm was not variolous. 
The march of the disorder would convert suspicion 
into certainty. The pustular syphilitic eruption runs a 
tedious course, exceeding ten days. The pustules are 
developed, not simultaneously, as in small pox, but in 
successive crops. 

[Dr. Watson mentions one patient under his care, in whom " the 
papula? of small pox were, at the outset, so intermingled with the 
appearances and sensations of urticaria, that he doubted, for twenty- 
four hours, what the true character of the eruption might be." — (Prac. 
o/Pfojs., p. 978; 3d edit., 1847.)] 

From the earliest periods, much attention has been 
paid to the statistics of small pox. The absolute num- 
bers carried off by it, and the relative numbers of those 
who die to those who are attacked, have alike been 
made the objects of inquiry. The old bills of mortality, 
which can be trusted to more in plague and small pox 
than in any other disorder, give 199,665 as the total 
amount of deaths by small pox in London during the 
last century, of whom 97,546 perished in the first half, 
and 102,119 in the second half. During the last quar- 
ter of the last century, from 1775 to 1800- — that is, 
prior to the discovery of vaccination, — the proportion 
of the mortality by small pox to the total mortality, was 
as 8 to 100 in London, and we may reasonably con- 
clude that the same proportion existed throughout the 
country. Sir Gilbert Blane and others fancied that 
this ratio was steadily augmenting in consequence of 



MORTALITY OF SMALL POX. 



71 



the spread of inoculation, but I shall show you after- 
wards that this notion was unfounded. 

All authors have remarked, that the greatest mor- 
tality by small pox takes place in the early periods of 
life. Dr. Hay garth computed, that at Chester, in 1795, 
one half of the deaths among children below ten years 
of age was due to small pox. The same law holds 
good at present. From particulars to be found in Mr. 
Fair's first and second reports, I have drawn up the 
following table, which shows that out of every nine 
persons who now die of small pox in England, seven 
are below the age of five years. 

Ages of 9*762 persons who died of Small Pox in England, during the 
years 1837 and 1838. 



Under the age of 5 years, . 


7340 


deaths 


Between the ages of 5 and 15, . 


. 1668 


u 


"15 and 30, . 


528 


u 


" "30 and 70, . 


210 


a 


Upwards of 70 years of age, 


16 


u 



Total 



9762 



[Ages of 158 persons who died of Small Pox in Neiv York, during the 
years 1840 to 1844 inclusive. 

Under 5 years, 
Between 5 and 10 years, 

" 10 and 20 " 

" 20 and 30 " 

" 30 and 40 " 

" 40 and 70 " 

" 70 and "80 " 
Unknown, 



Total 



411 deaths 


75 


u 


52 


u 


121 


a 


59 


u 


34 


u 


2 


u 


4 


u 



758 



72 



MORTALITY OF SMALL POX. 



Ages of 529 persons who died in Philadelphia of the same disease 
during the same years. 

Under 5 years, 
Between 5 and 10 years, 



10 and 20 
20 and 30 
30 and 40 
40 and 70 



315 de 
61 
30 
58 
41 
24 



tbs. 



Total 



529 



In Ireland, during the ten years ending June 6, 1841, of 58,006 
deaths from this disease, 49,038 were in those under five years of age. 

The statistics of Manchester, Liverpool, Edinburgh, Glasgow, Perth, 
and Dundee, for 1839, show that the rate of mortality by small pox 
during that year was from 85 to 89 per cent, of those under five years 
old. 

The following table by Dr. Watt, of Glasgow, showing the per 
centage of deaths by this disease at different ages to the whole number 
of deaths in the cities of Glasgow, Edinburgh, New York, and Phila- 
delphia, is uot without interest in this point of view : — 





Glasg. 


Edinb. 


JV. Y. 


Fhila. 


Under 2 years, 


57.76 


53.24 


34.11 


34.39 


" 5 " 


85.72 


82.68 


58.66 


57.14 


« 20 " 


95.12 


95.23 


72.74 


77.24 


Above 20 " 


4.87 


4.76 


27.25 


22.75 



It will be seen by this, that the proportion of deaths by small pox in 
New York and Philadelphia, under two years of age, is above 23 per 
cent, less than in Glasgow ; while there is a corresponding increase in 
the proportion of deaths at the higher ages ; while the proportion of 
deaths at the early ages is the same in these two American cities. Dr. 
W. considers it highly probable that inattention to early vaccination 
may be the immediate cause of a greater mortality at the higher ages 
in America than in Great Britain. (Amer. Jour. Med. Science, April, 
1845— p. 515.)] 

When the registrar-general of England first began 
his labors (July 1, 1837), it was found that, notwith- 
standing the benefits of vaccination, there were still 
only four diseases which stood before small pox with 



MORTALITY OF SMALL POX. 73 

reference to the actual amount of mortality. Those 
still more fatal complaints were — consumption, convul- 
sions, tvphus fever, and pneumonia. In the second 
half of 1837 there died, throughout England and 
Wales, hy small pox, 5811 ; and in the metropolis, 763. 
The year 1838 was remarkable for the epidemic preva- 
lence of small pox throughout this country. In that 
year there died by small pox in England and Wales 
no less than 16,268 persons, of whom 3817 died in 
London. In 1839, a marked diminution took place. 
The deaths over the whole country amounted only to 
913 J, and in the metropolis to 634, which, as com- 
pared to the total mortality in that year, is little more 
than 3 in 100. 

At the Small Pox Hospital, the admissions, from 
1776 to 1800 (a period of twenty-five years), were 
7017— -and the deaths 2277, being at the average rate 
of thirty-two and a half per cent. From 1801 to ]825 
(a like period), the admissions were 3743, and the 
deaths 1118, being at the average rate of thirty per 
cent, of those attacked. Since 1825, the proportion of 
deaths to admissions has experienced a further diminu- 
tion. At the present time the deaths do not exceed 
twenty-five per cent, and in some years they have 
fallen as low as twenty per cent., or one in five. Tak- 
ing the world throughout, and making allowance for 
the character of cases which are usually sent to a 
hospital, we may state the average mortality by small 
pox at one in six of those attacked. Now this is 
exactly the calculation made by Dr. Adams thirty-five 
years ago, when he said that small pox occasioned very 
nearly a double decimation. 

The proportion of severe to mild cases is a subject 



74 



PROPORTION OF SEVERE CASES. 



which merits attention. The following table, which 
exhibits an analysis of the cases admitted into the Small 
Pox Hospital during four years, with the deaths in each 
respective class, will show, at one view, the numbers 
admitted, the comparative severity of the cases in the 
respective years, and the amount of mortality. 

Table exhibiting the proportion of Severe to Mild Cases, admitted into 
the Small Pox Hospital, in the Years 1837, 1838, 1839, and 
1841. 



CHARACTER OF THE 
DISORDER. 


1837. 


1838. 


1839. 


1841. 


TutHl in 
Four Years. 


Ad- 
mitted 


Died. 


Au- 
milted 


Died. 


mitted 

48 
31 

48 
145 


Died. | 


Ad- 
mitted 


Died. 


Ad- 
mitted 


Lied. 

304 
20 

8 

3 


Confluent Cases . . . 
Semi-confluent . 
Confluent & Semi-con- ) 
fluent Modified . . \ 
Distinct &. Varicelloid 

Total .... 


104 

45 

18 
72 

239 


42 

3 

1 



351 
120 

69 

154 


170 
12 

5 

1 


25 

1 ( 

1 


134 
71 

38 

99 


67 
4 

1 

2 


63; 

267 

143 
373 


46 


r;94 


188 


27- 


342 


74; j 1420 


335 



In the foregoing table it will be perceived that the 
vaccinated and unvaccinated are classed together, the 
object of the table being to show the proportion which 
the mild bear to the severe cases, without reference to 
the cause of such discrepancies. It will also be seen that 
the confluent and semi-confluent cases taken together 
exceed the half of the admissions ; that nearly one half 
of the confluent cases prove fatal, and about one in ten 
of the semi-confluent cases. The deaths in the remain- 
ing classes are to be looked upon only as accidental and 
superadded events. 

The next table that I lay before you carries the 
analysis still further, and shows the comparative severity 
of the cases, as they occurred among vaccinated and 
unvaccinated subjects. This table I have given for one 
year only, 1838, the year of epidemic prevalence. 



COMPARATIVE MORTALITY. 



75 



Tabic exhibiting the Comparative Mortality of the several varieties of 
Normal and Abnormal Small Pox, occurring at the Small Pox 
Hospital, during the epidemic of 1838, distinguishing the vacci- 
nated from the unvacc incited. 



NORMAL SMALL POX. 


Unprotected. 


Vaccinated. 


Admitted. 


Died. 


Admitted. 


Died. 


Confluent 

Semi-confluent .... 
Distinct 

Total Normal . . 

Confluent Modified . . 
Semi-confluent Modified . 
Varicelloid 

Total Abnormal . . 


295 

78 
19 


149 

8 



56 
42 
20 


21 
4 



392 


157 


118 


25 


2 
1 

1 







38 

28 

114 


4 
1 
1 


4 





180 


6 


396 


157 


298 


31 



This table shows how remarkable is the power of 
vaccination in altering the proportion of severe to mild 
cases. It will be seen that among 396 unprotected 
cases, there were only 23 which were mild in their 
aspect ; while out of 298 vaccinated subjects, there were 
no less than 134 which presented, from the onset, favor- 
able appearances, independent of 66, which displayed 
modification during the maturative stage. 

The next point which merits attention is the period 
of disease at which death takes place. Small pox may 
prove fatal at any period from the first invasion of fever 
to the fortieth day. Death may even take place prior 
to the development of eruption, but such cases are rare. 
In all countries it is observed that the second week is 
that which exhibits the greatest amount of mortality, 
and the eighth day the day of greatest danger. The 



76 



FATAL PERIODS. 



subjoined table, extracted from the records of the Small 
Pox Hospital for 1828-9, shows the period of eruption 
at which 168 patients died. The dates of their decease 
prove satisfactorily that no importance can be attached 
to the doctrine of critical days in the fever of small pox. 

Table exhibiting the Days on which 168 Cases of Small Pox proved 
fatal, at the Small Pox Hospital, 1828-29. 



Days. 


Fatal 

Cases. 


Days. 


Fatal 

Cases 


Days. 


Fatal 
Cases. 


3d 


1 


13 th 


11 


24th 


3 


4th 


5 


14th 


5 


25th 


1 


5 th 


10 


15th 


7 


27th 


1 


6th 


5 


10th 


5 


28th 


1 


7th 


11 


17th 


3 


29th 


1 


8th 


27 


18 th 


3 


31st 


1 


9th 


15 


19 th 


1 


32d 


1 


10th 


14 


20th 


2 


35th 


1 


11th 


16 


22d 


3 


38th 


1 


12th 


11 


23d 


1 


39th 


1 



We may otherwise arrange these cases by saying, 
that there died 

During the 1st week (3d day to the 7th), 32 Patients. 

2d week (8th to 14th), . . 99 " 

" 3d week (15th to 21st), . . 21 " 

" 4th week (2 2d to 27th), . . 9 " 

" 5th and 6th weeks, ... 7 " 

It may be useful, in connexion with these statistical 
details, to recall to your recollection the principal cir- 
cumstances to which the fatal event in small pox is more 
immediately attributable. 1. Prior to the maturation 
of the pustules (that is, during the first week), small pox 
proves fatal by that general derangement of the w T hole 
system, and more especially of its fluids, which we 
usually designate by the term, acute malignancy. No 
marked lesion of any internal organ would be traced on 



DIRECT CAUSES OF DEATH. 77 

dissection. 2. During the second week of eruption, the 
chief cause of death will be found in the specific affec- 
tion of the trachea and larynx, and consequent asphyxia. 
3. During the third week, when secondary fever has 
begun its work of devastation, death may happen, either 
by effusion on the brain (hydrocephalus), or by super- 
vening pleurisy, pneumonia, or laryngitis, or lastly, by 
gangrenous destruction of portions of the skin. During 
the 4th and subsequent week, death may be the direct 
consequence of erysipelas, or of some other complaint 
excited by the small pox, or engendered by that debility 
which small pox, in any of its severer forms, so frequently 
entails. 

[M. Trousseau remarked, in speaking of a case of death from discrete 
variola, that the exactness of a rule given by Sydenham, and repeated 
after him by Von Swieten & Stoll, was verified in it, viz. that when 
there is no tumefaction of the face and eyelids in variola, death takes 
place on the 9th or 10th day if the disease is discrete, and on the 13th 
or 14th if it is confluent. (Clin, des Hop. des Enfanls ; quoted by Lon- 
don Lancet. American Republication, May, 1S46, p. 442.)] 

The phenomena and statistics of small pox being now 
described, I proceed to explain to you its causes, — to 
unfold what is known regarding; its origin and mode of 
propagation, and the circumstances under which it com- 
monly displays itself. This we call (he pathology of 
the disease, by which is understood everything that can 
be learned concerning a disease by reasoning upon 
acknowledged phenomena. 

For more than a thousand years after the first appear- 
ance of small pox in Egypt, its causes were sought for 
in the condition of the blood, or in those circumstances 
of the body, or of the atmosphere which surrounds the 
body, which were believed, and justly too, to give rise 



78 PATHOLOGY OF SMALL POX. 

to common fever. Defects (or vitia) of one or more of 
the non- naturals were the presumed sources of small 
pox. The non-naturals were six in number — namely, 
air, aliment, the secretions, sleep, exercise, and mental 
emotion. Contagion was admitted as an accessory 
cause. To this day, a large portion of mankind believe 
that small pox may be bred in the blood, like gout or 
rheumatism, independent of all direct external agency. 
Boerhaave was the first physician who abandoned these 
views, and professed his belief that small pox was in all 
cases the product of a specific poison or miasm, derived 
from some one already laboring under the malady. He 
acknowledged that the miasm must originally have 
sprung from some fortuitous combination of common 
causes, and that what had happened once might of 
course happen again ; but he held that this contingency 
was improbable, and might be excluded from our rea- 
sonings. 

The correctness of this view of the origin of small 
pox, and of the zymotic maladies associated with it, is 
now generally admitted. No doubt it is difficult to 
explain every case that occurs on the principle of specific 
contagion, and many specious arguments in favor of 
occasional spontaneous origin might be adduced ; but 
we should remember that anomalies would often admit 
of easy explanation, were the circumstances of the case 
thoroughly known. One illustration may suffice. In 
1835 a child took small pox in the country, under cir- 
cumstances which seemed to exclude all suspicion of 
contagion. She had never left the house for several 
weeks, the few neighbors who had called were free from 
sickness, and no small pox existed in the neighborhood. 
During her convalescence, a looking-glass being put 



SPONTANEOUS ORIGIN. 79 

into her hands, she immediately said, "My face is 
exactly like that of the child at the door from whom I 
bought the beads." On inquiry, it was found that some 
pedlars had passed through the village, and that the 
child, though she had never left the house, had been to 
the door. Had this child either died, or been an inat- 
tentive observer, the origin of this attack of small pox 
must, on the principle of contagion, have remained for 
ever mysterious. The circumstance already adverted 
to — that small pox has never yet been seen in Australia 
and Van Diemen's Land — gives great support to this 
doctrine. 

While we thus admit the theory of an invariable 
origin from contagion, we must not shut our eyes to 
the importance of the facts which connect small pox 
with other epidemic maladies, such as malignant cho- 
lera, influenza, and hooping cough, where the notion of 
contagious origin is either given up, or only admitted 
partially. 

[It is this very connexion of small pox with other epidemic maladies 
to which, our author alludes, and the importance of which he wishes to 
impress upon us, that led Mr. Webster to insist so strongly upon the at 
least occasional generation of this and the other exanthematic diseases 
independently of any external infecting cause. He says the first case of 
these diseases in every epidemic period is always generated in the human 
body without contagion. When the condition of the elements is fitted 
to produce them, they appear in all parts of the country without conta- 
gion, spread rapidly, and decline when the general causes cease to 
operate. During this period contagion is efficacious in propagating 
them, and no longer. [History of Epidemic Diseases, vol. ii. p. 90.) 

Prof. Joseph M. Smith [Etiology and Philosophy of Epidemics, New 
York, 1824, p. 155) admits that they may all originate independently 
of contagion, and is inclined to think that small pox most rarely occurs 
de novo during its epidemic prevalence, and next to this measles, then 
scarlet fever, chicken pox, and hooping cough. 

Mr. Ceely, of Aylesbury (England), seems to consider it as settled 



80 SPONTANEOUS ORIGIN. 

that the variolas vaccinas originate spontaneously. He says that it is 
not doubted by the farriers of that place, and that, in all the cases he 
has observed, he could never discover the probability of any other 
source. (Observations on Variolse Vaccinas. Trans. Pr ovine. Med. and 
Surg. Assoc, vol. viii. p. 300.) 

If the cow pox thus frequently originate, analogy would seem to offer 
strong reason in favor of a similar origin, at least occasionally, of the 
human small pox, which so closely resembles it. 

It must be acknowledged respecting them all, and especially with 
reference to measles, scarlet fever, and hooping cough, that they some- 
times occur in such a manner and under such circumstances as almost 
to exclude the idea of contagion. 

A striking instance of a case of variola without obvious contagion, is 
given by Dr. Banks, of Lawrenceville (III.), in the P 'hiladelphia Medical 
Examiner, new series, vol. v. p. 519, from which it is quoted in the 
Brit, and For. Med. Chir. Rev., April, 1850, p. 533. The case pre- 
sents several points of interest. The editor of the Examiner refers also 
to two other cases, where the idea of contagion seemed to be out of the 
question.] 

To understand, therefore, the origin and propagation 
of small pox, you must view it, not only as a contagions, 
but as an epidemic disorder. And first, of the conta- 
gious origin of small pox. 

Contagious emanations are given off from the human 
body at every stage (,f small pox, from the first invasion 
of fever to the throwing off of the latest scabs. Heber- 
den and Haygarth believed that for the first few days, 
and during the initiatory fever, a patient seldom, if ever, 
communicated the infection ; but this notion is erro- 
neous. I have even been tempted to think that in the 
very earliest periods of the disease the communicating 
power is most energetic. 

[Heberden fixes the probable time of communication at the sixth day 
of the eruption. Chapman {Eruptive Fevers) agrees with Heberden, 
but thinks it probable that, as in the instance of the vaccine affection, 
the contagion may exist in the vesicle as well as in the pustule. 



PREDISPOSING CAUSES. 81 

Prof. A. Clark, of this city, from a careful examination of the cases 
which have occurred at the New York Hospital for a series of years, is of 
the opinion that the disease is not communicated until the eruption has 
reached the vesicular form.] 

The dry scabs of small pox retain a contagious 
property for a great length of time. Experience, too, 
has taught us that death does not destroy the energy of 
the purulent secretion. A child has been successfully 
inoculated with matter taken from the dead body. A 
confluent case will taint the air and spread infection for 
at least ten or twelve days after death. The know- 
ledge of this fact has induced the Secretary of State to 
issue orders that the bodies of those dying of small pox 
are not to be admitted into the schools of anatomy. 

The circumstances that determine the quantity of 
eruption and the general character of the disease are 
not well known, though many attempts have been made 
to throw light on this obscure branch of exanthematic 
pathology. Nothing is better ascertained than that the 
disorder produced bears no necessary relation to the 
disorder producing. A confluent case shall give origin 
to a varioloid, and a mild distinct, nay, even a varicel- 
loid, or highly modified case, shall generate in another 
person malignancy and confluence. The predisposition 
to the reception of the variolous germ is an interesting 
branch of this inquiry. Persons in the best health take 
small pox, and, upon the whole, are more apt to take 
the disease than those who are out of health, just as we 
find it most easy to vaccinate successfully the ruddiest 
and finest children. The state of mind generally said 
to be most favorable to the reception of the virus is a 
dread of the disease. There is probably some truth in 
this statement, but you will meet with exceptions to the 

6 



82 PREDISPOSING CAUSES. 

rule, almost as numerous as the illustrations of it 
Change of air decidedly predisposes the body to receive 
infection. But this is a law of the animal economy of 
very wide application. It is this same principle, applied 
to endemic fevers, which leads to the phenomena of 
seasoning and acclimatization. You know that a regi- 
ment arriving in the West Indies, or the crew of a ves- 
sel first entering the Bonny or Calabar, are almost sure 
of suffering from the remittent fever of those climates. 

The quantity of eruption in any particular case is 
sensibly influenced by the state of the surface at the 
precise moment of development. Whatever tends to 
augment the cutaneous circulation, such as the warm 
bath, abundant bed-clothes, strong diaphoretic and su- 
dorific medicines, cordials, wine, heat of the apartment, 
all concur in favoring confluence. The proved effect 
of heat in promoting, and of cold in repressing eruption, 
formed the keystone of the Suttonian practice of inocu- 
lation. Small pox is almost always confluent, and fre- 
quently fatal, when it occurs to a woman in child-birth. 
Much may in this case be attributed to heat. 

All local irritants, such as blisters, mercurial inunc- 
tion, and plasters, favor confluence in parts to which 
they have been applied. Active purgatives, taken dur- 
ing the incubative stage, lessen the quantity of eruption 
by causing derivation of the fluids from the skin to the 
bowels. A plethoric state of body equally disposes to 
confluence, while it adds to the general severity of the 
disease, and is the main cause of cellular complication. 
Extreme weakness of frame delays the eruption, and 
dangerously represses that inflammatory process which 
is essential to the repair of the injury inflicted by the 
poison on the skin. 



MIASMATIC ORIGIN. 83 

Lastly: it may be remarked that there exists in cer- 
tain individuals, and not unfrequently in members of 
the same family, a peculiar irritability, under the influ- 
ence of the variolous contagion, just as some persons 
suffer severely from the smallest doses and the mildest 
preparations of mercury. The petechial form of small 
pox has for its cause this idiosyncrasy, or peculiarity of 
habit. Such constitutions receive small pox with alarm, 
develope it with difficulty, and sink under its elimina- 
tion. On the other hand, other persons imbibe the 
morbid germ mildly, nourish it without suffering, and 
eliminate it safely and kindly. 

The miasm of small pox belongs to every part of the 
body. It is given off both by the lungs and by the skin. 
The breath, the secretions, the matter of the pustules, 
the scabs, all contain it It attaches itself to fomites, 
more especially the clothes of the patient, the bedding, 
and the bed furniture. These, if closely wrapped up, 
and secluded from the air, will retain the miasm, and 
give it out in an active state at great distances of time. 
But free exposure to the air greatly diminishes or alto- 
gether destroys this infecting property ; for the conta- 
gion, whatever be its intimate nature, is very volatile. 
The medical attendant, therefore, who goes into the 
open air after visiting a small-pox patient, is seldom 
found to communicate the disorder. Very absurd stories 
have been gravely told regarding the time during which 
fomites may retain their active powers. A physician at 
Plymouth describes a case of small pox originating in 
contagion brought from London in a periwig. Another 
doctor assures us that he knew a maid-servant who took 
small pox by washing the floor of a room two years 
after any small pox patient had been in it. 



84 EPIDEMIC DIFFUSION 

Experiments were made in 1832, by direction of the 
Royal College of Physicians of London, for the purpose 
of determining the power which a high temperature and 
chlorine gas are said to possess of destroying the activity 
of variolous contagion ; but the results were unsatisfac- 
tory. The sphere of contagious influence has been 
much questioned. Dr. Hay garth's opinion was that it 
was very limited, not extending more than a few feet 
from the patient's body. On the other hand, an Ameri- 
can physician, corresponding with Dr. Hay garth, affirms 
that the contagion, on one occasion, crossed a river 
1500 feet wide, and affected ten out of twelve carpen- 
ters at work on the other side ! It is undoubtedly very 
difficult to fix the distance at which the variolous poison 
ceases to be energetic ; but it is almost certain that the 
constitution of the air, in epidemic years, permits a very 
wide diffusion of the germ. 

Variolous matter may be diluted with water without 
its properties being in any degree altered. Dr. Adams 
first established this fact, which has since been corrobo- 
rated by the analogous experiments of M. Bousquet 
with regard to cow pox. 

We must now view small pox as an epidemic disor- 
der, as one that spreads in particular seasons, and in 
certain districts, without our being able to ascertain why 
that district, or season, is subject to such a visitation. 
The great epidemics of the last hundred years, in Lon- 
don, have been those of 1757, 1781, 1796, 1825, 1838, 
and 1844, the respective intervals between which have 
been 24 years, 15 years, 29 years, 13 years, and 6 years. 

Epidemic visitations, whether of small pox, or of any 
other allied malady, acknowledge alike the law of rise, 
culmination, and decline. They advance gradually, 



OF SMALL POX. 85 

attain their crisis or height, and then gradually decline. 
Mr. Farr has, with his usual ingenuity, traced the laws 
which appear to govern each of these stages of epidemic 
progress, and he arrives at the conclusion that epidemic 
decline is always less rapid than its advance. 

[It may not be uninteresting to state more particularly the law of the 
rise and decline of small pox to which our author alludes. Mr. Farr 
says u . it appears probable that the small pox increases at an accelerated 
and then at a retarded rate ; that it declines first at a slightly accele- 
rated, then at a rapidly accelerated, and lastly at a retarded rate, until the 
disease attains the minimum intensity and remains stationary." The 
same law is said to apply also to measles, scarlet fever, and hooping 
cough, in London.] 

Sydenham remarked that when a small pox epidemic 
is mild, it begins about the vernal equinox (March 25) ; 
but when of an extended and dangerous kind, it begins 
in the month of January. These observations are not 
confirmed by modern statistics. The last epidemic 
which the metropolis experienced began in November, 
1837, reached its acme in June, 1838 (being a period 
of eight months) — then slowly declined, and ceased 
entirely in January, 1839, extending thus through a 
period of fifteen months. The epidemic of 1796 fol- 
lowed a course very similar in all respects. 

Some epidemics are local, some are very extended. 
Small pox broke out in Norwich in 1819, and destroyed 
530 persons in that city between the months of May 
and October. It did not spread to other parts of the 
country. The epidemic small pox, the most remark- 
able for its extensive diffusion which perhaps ever 
occurred in the world, was that which began in Swe- 
den, in 1824, — reached England in 1825, spread to 
France in 1826-27, and ceased, in Italy, in 1828-29. 



86 EPIDEMIC DIFFUSION OF SMALL POX. 

The effects of this epidemic were very remarkable, and 
will be noticed hereafter, when the results of vaccina- 
tion are laid before you. Mr. Farr, in his second 
Report (1840), has given a very interesting table, show- 
ing the rise, culmination, and decline of the variolous 
epidemic of 1838, in each of the great districts of Eng- 
land. From this table it appears that the epidemic 
commenced in Liverpool in 1837, spread through the 
southwestern counties to the metropolis, diverged to 
Manchester and Leeds, raged in the eastern counties 
during the first half year of ]839, and then returned to 
its old haunts in Lancashire, after making a sweep 
around the island. From this fact alone we might 
learn, what innumerable other observations teach us, 
that the miasm of small pox is very indifferent to sea- 
sons, that the frosts of winter and the heats of summer 
are alike congenial to it. 

Small pox will sometimes spread in a cold and moist 
state of the air, sometimes when the atmosphere is clear, 
bright, or frosty. Nothing, in fact, has ever been 
observed, either with respect to the temperature, the 
moisture, the winds, or the general character of the 
atmosphere, which can throw light on the sources of 
epidemic visitation. It is worthy of remark, that the 
mortality by small pox always increases in years of 
epidemic prevalence. Small pox is then not only more 
abundant, but more severe than when it occurs as a 
sporadic malady. The difference in the rate of mor- 
tality may amount to ten or even twelve per cent. 

The susceptibility of small pox next claims our 
attention. All mankind, with few exceptions, are born 
with a susceptibility of small pox. The European, the 



SUSCEPTIBILITY TO SMALL POX. 87 

negro, and the Hindoo, in this respect, at least, arc on 
a par. This susceptibility, unless altered by vaccina- 
tion, remains equally strong at all ages. Children, 
indeed, are the especial victims of small pox, but this is 
merely because the disease is usually contracted on the 
first occasion of exposure to the miasm. There died 
in London of small pox during the two years 1840-41, 
2286 persons, of whom 2060 were under, and only 226 
above 15 years of age. Nevertheless, to this law there 
are occasional exceptions. Persons have been known 
to go through life, exposed frequently to the contagion, 
yet never take it. Prior to the discovery of inocula- 
tion, and indeed after it, many thousands of mankind 
attained a good old age without ever experiencing an 
attack of small pox. Yet persons exhibiting this natural 
unsusceptibility, have nevertheless, late in life, received 
the disease by inoculation. A lady residing in Salis- 
bury was successfully inoculated for small pox in 1804, 
at the age of eighty-three, and lived several years after- 
wards. She had brought up a large family, many of 
whom she had attended in an attack of small pox, but 
had never taken it herself. A few persons pass through 
life apparently insensible to the variolous virus, whether 
casually or by inoculation; but such cases are rare. 
This very estimable privilege has been said to attach 
to particular families, but there is no foundation for the 
notion. 

The great discovery of modern times is, that an 
unsusceptibility, or at least a deferred susceptibility of 
small pox, may be given to man artificially. We may 
so alter and modify the state of his blood that he can- 
not take it. I need hardly tell you, that this expedient 
is vaccination. The security which it affords may be 



88 RECURRENCE OF SMALL POX. 

permanent through life, or only temporary; but observe, 
— this is no more than happened to a few favored indi- 
viduals, by an inexplicable idiosyncrasy, before Jenner 
was born, or vaccination dreamed of. 

If there are people in the world who cannot be made 
to take small pox, this is more than compensated by 
those who have the bad luck to fall into it twice. 
Cases of secondary or recurrent small pox have been 
described in all ages, from H hazes down to our own 
times. They were never very common — rarce aves 
always — but they have occurred, and they may occur 
again. You must not, however, give credit to all that 
you hear said nowadays on the subject of secondary 
small pox. One gentleman, in reply to the queries of 
the Provincial Medical and Surgical Association, 
informed us, that in his own practice he had attended 
between eighty and ninety cases of recurring small 
pox ! He even goes further, and avers that he knows 
two families where small pox occurred a third time. 
Contrast with this the opinions of Dr. Mead, Dr. He- 
berden, Dr. Monro, De Haen, and other practical men 
of the last century, who hesitated very much about the 
possibility of genuine small pox recurring. Remember 
that De la Condamine, in 1754, estimated these cases 
at one in ten thousand; others, at one in five thousand. 
At the Small Pox Hospital, very few persons ever pre- 
sent themselves who affirm that they have previously 
undergone small pox ; and of the few who do, but a 
very small fraction can stand the test of rigid scrutiny. 
In one of the last cases that occurred, a medical man 
who witnessed the first seizure had misgivings as to the 
true nature of the case. No instance is recorded of 
the same person having been admitted twice into the 



RECURRENCE OF SMALL POX. 89 

Small Pox Hospital. You may ask me why I am thus 
incredulous on the subject of recurrent small pox ? It 
is not that I have any theory to support, but it is 
because I know there are so many sources of fallacy. 
Sometimes the first case is incorrectly reported ; some- 
times the second. It is very rare that the same medi- 
cal man sees and reports both the seizures. I have 
seen three cases of pustular syphilis so like small pox, 
that a careless observer, — nay, even a very careful 
observer, were he only to see the case once, might 
easily be deceived. But it is not only the pustular 
forms of syphilis which gives rise to mistakes. Lichen, 
and, above all, varicella, are fruitful sources of error. 
I was once called in to see a case of alleged secondary 
small pox, which, on investigation, proved to be 
ecthyma. I have even seen psora mistaken for small pox ! 
In Dr. Baron's Life of Jenner (vol. i. p. 278), it is 
remarked, " that when Jenner's discovery was first 
announced, it had escaped the attention of medical men 
that small pox occurred a second time so frequently, as 
it has since been proved to do, both by recent experi- 
ence and past history." " Such an impression," adds Dr. 
Baron, " led to a too confident announcement of the 
never-failing efficacy of vaccination." It is scarcely 
conceivable that Jenner, who for thirty years had been 
studying small pox closely, should have been so ill-in- 
formed on one of the most curious points of variolous 
pathology as is here alleged. It is difficult to believe 
that a principle of such importance should have escaped 
observation at a period when men's minds were so 
strongly drawn to the subject, and have attracted notice 
only when small pox was comparatively rare. The 
probability, therefore, is, that Jenner was correct in his 



90 CASE OF LOUIS XV. 

early views of the permanency of the protection which 
one attack of small pox afforded, and that the ardor of 
his followers in their support ( f vaccination led them 
to overrate the frequency of recurring or secondary 
small pox. 

With this impression strong upon my mind, I cannot 
go far into the history and peculiarities of recurrent 
small pox. I may, however, state to you, that some 
pathologists connect the phenomenon with a peculiar 
proneness in the system to suffer under the variolous 
virus. They argue thus, from observing that all well 
authenticated cases of second small pox have been of 
persons who in the first instance took it severely. 
Another class of pathologists explain the circumstance 
by supposing that the first attack had not been in suf- 
ficient intensity to absorb the whole amount of suscep- 
tibility. They argue thus, from having noticed that 
the first attacks have been mild. This question I can- 
not undertake to decide, — tantas componere lites. 

The most remarkable case of recurrent small pox on 
record is that of Louis XV., king of France, who died 
of it in the year 1774, at the age of sixty-four, after 
having, as it is alleged, undergone that disease casually 
in 1724, when he was fourteen years of age. I have 
been at some pains to investigate this case, which cre- 
ated a great sensation at the time, has been quoted over 
and over again, and to which great importance has 
been attached. After careful inquiry into dates, the 
character of the incubative stage, and the course of the 
eruption, I convinced myself that his Majesty never 
had small pox in early life, and that the primary attack 
was varicella. 



COMMUNICATION TO THE FCETUS. 91 

[For remarks on the occurrence of small pox a second time in the 
same individual, and statistics showing its comparative frequency, see 
Appendix D.] 

Among the peculiarities of small pox, the possibility 
of its occurring simultaneously with other exanthemata 
must not be omitted. Measles and small pox have 
appeared together, and run their respective normal 
courses, uninfluencing each other. At the Small Pox 
Hospital, I have seen many unequivocal cases of the 
concurrence of small pox and scarlatina anginosa. 
Small pox and cow pox may co-exist, as I shall after- 
wards more fully explain. Sometimes each disorder 
runs its natural course. Occasionally one or other 
malady is modified either in aspect or progress. 

[For instances of co-existence of small pox with other exanthemata, 
see Appendix C, before referred to.] 

There remains only one topic connected with the 
pathology of small pox. on which I would wish to 
address you ; and that is, the communicability of the 
disease to the foetus in utero. Dr. Jenner, Dr. George 
Pearson, and others, have collected many curious facts 
on this subject, and I am desirous to acquaint you with 
some of the most interesting of them. To do full jus- 
tice to the subject would lead me into a wide but 
unprofitable path. 

It does not necessarily happen that a pregnant woman 
taking small pox conveys the disease to the child. 
Several instances to the contrary have occurred at the 
Small Pox Hospital. An opinion was entertained by 
Dr. Mead (but erroneously), that in cases where a 
woman undergoes small pox without aborting, the infant 
would remain through life unsusceptible, having, in fact, 
passed through the disease in utero. Dr. Jenner has 



92 COMMUNICATION TO THE FCETUS. 

detailed two cases which prove very satisfactorily that 
a foetus in utero may contract small pox, provided the 
mother be exposed to the contagion, although she her- 
self does not take it. An infant born under these cir- 
cumstances sickened for the small pox five days after 
birth, and twelve from exposure to contagion. 

In a large proportion of cases, small pox communi- 
cated by the mother to the foetus destroys the infant's 
life. The child is often still-born. 

[For particulars of the cases reported by Dr. Jenner, referred to by 
our author, and a record of other cases and references on the subject, 
see Appendix E.] 

In the neighboring museum of Guy's Hospital there 
formerly was, and perhaps is still, a foetus preserved, 
whose skin is covered with variolous pustules. Mr. 
Heaviside's museum contained a similar case. 

[A very well marked and well preserved specimen of the same kind 
is to be seen in the Museum of the College of Physicians and Surgeons, 
of this city.] 

The earliest period of foetal life at which I have ever 
seen traces of variolous eruption is four months. 

It is very seldom that a pregnant woman dies of 
small pox without aborting, or giving birth to the child. 
This seems to be a very general law of nature, applica- 
ble to all severe maladies, whether acute or chronic. A 
pregnant female, if consumptive, lives to give birth to 
her child, though she herself may sink, exhausted, within 
a few hours afterwards. It is apparently a provision of 
nature, giving to the offspring, under all circumstances, 
the best chance of life. The principle is illustrated in 
the history of scarlet fever, not less remarkably than in 
that of small pox. 



LECTURE V. 

MANAGEMENT OF SMALL POX. 

Erroneous notions formerly entertained on this subject. Sources of danger 
in small pox. Treatment during the initiatory fever. Question as to the 
employment of blood-letting. Treatment during the maturative stage. 
Treatment of the mucous implication. Local treatment of the pustules. 
Management of the petechial form of small pox. Treatment in the 
secondary fever. Controversy as to the employment of purgatives in 
small pox. Treatment of the sequelae of small pox. External treatment 
during secondary fever. Inoculation of small pox. Mode of practice. 
Phenomena of inoculation. Results of inoculation. Abolition of inocu- 
lation. 

The power of medicine over small pox is not so striking 
as it is over inflammations, over bowel complaints, over 
agues, or many other types of fever. Nevertheless, 
medicine does exert a certain amount of influence over 
the course of this disease. Whether it does so, how- 
ever, or not; whether the amount of that influence be 
great or small ; in either case the management of small 
pox must be carefully investigated by you — first, lest by 
your measures you may do mischief, and make bad 
worse ; secondly, because the world expects you to do 
something for the benefit of your patient, and what that 
something is you must be taught, remembering always 
that improper treatment may do harm, though the very 
best may not do good. 

It is a melancholy reflection, but too true, that for 
many hundred years the efforts of physicians were 
rather exerted to thwart nature, and to add to the ma- 
lignancy of the disease, than to aid her in her efforts. 
Blisters, heating alexipharmics, large bleedings, opiates, 



94 ERRONEOUS NOTIONS OF SMALL POX. 

ointments, masks, and lotions to prevent pitting, were 
the great measures formerly pursued, not one of which 
can be recommended. What think you of a prince of 
the royal blood of England (John, the son of Edward 
the Second) being treated for small pox, by being put 
into a bed surrounded with red hangings, covered with 
red blankets, and a red counterpane, gargling his throat 
with mulberry wine, and sucking the red juice of pome- 
granates 1 Yet this was the boasted prescription of 
John of Gaddesden, who took no small credit to him- 
self for bringing his royal patient safely through the 
disease. We may smile at this ; but if either he, or 
Gordonius, or Gilbertus, were to rise from their graves 
and inquire whether this is one whit worse than Mes- 
merism, or at all more absurd than homoeopathy or 
hydropathy, we should, I fear, look a little foolish. Let 
us, then, avoid the errors of our ancestors, without 
reproaching them. 

Even physicians, in more recent times, have enter- 
tained very erroneous notions regarding the powers of 
medicine in the treatment of small pox, and the objects 
which ought to be kept in view. They imagined that 
certain drugs possessed a power of promoting the erup- 
tion of small pox, and not only of promoting it, but of 
procuring a favorable sort. They arrogated to them- 
selves a like power of controlling secondary fever, and 
preventing its necessary consequence — pitting. We 
pretend to no such power. We know that the system 
has imbibed a morbid poison, which, somehow or other, 
must be got rid of; and consequently we study to place 
the system in the most favorable circumstances for the 
safe elimination (or concoction) of the morbid matter. 
We propose to ourselves, therefore, 



SOURCES OF DANGER. 95 

1. To moderate the violence of febrile excitement 
whenever we meet with it. 

2. To check and relieve local determinations of blood, 
at whatever period of the disease they arise. 

3. To support the powers of the system when it flags, 
either from the malignity of the poison or the long 
continuance of the disorder. 

4. To combat, by appropriate means, concomitant 
disease. 

You will bear in mind what I told you in a preceding 
lecture of the various sources of danger in small pox. 
As it is very important, in undertaking the management 
of the disease, to keep these in view, I will recall the 
principal circumstances to your minds. Danger in 
small pox depends — 1. on the quantity of eruption ; 
2. on the condition of the mucous membranes ; 3. on 
the state of the fluids ; 4. on the state of the brain and 
nervous system ; 5. on the age of the patient ; 6. on 
his habit of body ; 7. on the circumstances in which he 
is placed. 

1. Distinct small pox is a disease of little or no 
danger. Confluence is always unfavorable, especially 
on the face ; nor is the danger always apparent. A 
confluent case shall sometimes appear to progress favor- 
ably, when, unexpectedly, a fit of convulsion occurs, and 
the patient sinks. The drain upon the system which 
excessive pustulation occasions is another source of 
danger ; nevertheless, if the pustules on the extremities 
acuminate well, and exhibit a crimson areola, a good 
ground of hope exists. If, on the other hand, the vesicles 
on the trunk and extremities be flat, with a clarety 
areola, while the eruption on the face is white and pasty, 
no reasonable hope of recovery can be entertained. 



96 SOURCES OF DANGER. 

2. The condition of the mucous membrane of the 
trachea is equally important. Hoarseness at an early 
period of the disease is always to be looked upon with 
suspicion. A natural tone of voice is a good omen, 
even though the eruption be full and confluent, with a 
disposition to cellular complication. 

3. The condition of the fluids in small pox is a fea- 
ture of the utmost importance in guiding your judgment 
as to the probable result of the case. Everything which 
indicates putrescency and a dissolved state of the blood 
is highly unfavorable. Petechias, mucous haemorrhages, 
menorrhagia, and vesicles filled with blood, preclude 
the hope of benefit even from the most judicious treat- 
ment. 

4. A tranquil state of the nervous system is peculiarly 
favorable, and the circumstance to which recovery in all 
severe confluent cases is mainly attributable. Quiet 
nights, composure of manner, a contented disposition, 
and confident hope of recovery, are among the most 
pleasing signs that can occur. Restlessness, a succes- 
sion of sleepless nights, constant moaning, and despond- 
ency, afford little prospect of eventual recovery. Chil- 
dren who grind their teeth seldom recover. 

5. Age is a point of great moment in estimating the 
decree of danger in confluent and semi-confluent cases. 
The extremes of life are those on which small pox 
always falls the heaviest. Persons above forty years of 
age seldom recover even from the semi-confluent small 
pox. Children are in danger from an amount of erup- 
tion that can scarcely be called semi-confluent. In 
both, the process of cicatrization is attended with great 
exhaustion of nervous power, the result of which is 
often the setting up of acute inflammation in an internal 



SOURCES OF DANGER. 97 

organ essential to life — either the brain, the larynx, or 
the lungs. The most favorable age for taking small 
pox is from the seventh to the fourteenth year, when 
the powers of life and reproduction are in their fullest 
vigor. 

6. The habit of body is also to be taken into account. 
Small pox is always aggravated by its concurrence with 
a state of plethora. Constitutional debility is equally 
to be dreaded. In the strumous habit, the sequelae of 
small pox are peculiarly severe, and often threaten the 
loss of life when the first dangers have been passed. 

7. The probability of recovery must depend, lastly, 
on the circumstances in which the patient is placed, — 
on the possibility of applying remedial measures effec- 
tively, on the treatment which may have been pursued 
in the early stages, and other contingencies, which 
scarcely admit of enumeration. In hospitals, the risk 
of contracting erysipelas, and falling under the influ- 
ence of hospital miasm, must never be lost sight of. 
In private life, again, the anxieties of friends may 
prompt a more stimulating regimen than prudence 
would dictate ; and thus may local congestions and 
inflammations be excited, from which the hospital 
patient is exempt. 

With respect to the initiatory fever of small pox, it is 
either known or not known that small pox is approach- 
ing. If it be not known, then the case is necessarily 
treated as one of common fever, to which ordinary rules 
apply. On the other hand, if it be known, or strongly 
suspected, that the variolous poison is circulating, then 
the question arises, should there be any corresponding 
difference of treatment 1 Are you, on that account, to 

7 



98 TREATMENT IN INITIATORY FEVER. 

refrain from bleeding, or to practise it 1 — to give a pur- 
gative, or to withhold it 1 It is always desirable to 
ascertain, if possible, the fact of variolous origin, for the 
same reason that it is better for a man to work in day- 
light than in the dark, but the differences in treatment 
are not material, as you will soon perceive. 

In the initiatory fever of small pox, the antiphlogistic 
treatment is to be pursued, except in a few special 
cases. The surface is to be kept moderately cool. A 
brisk cathartic, composed of four grains of the chloride 
of mercury, with eight of the compound extract of colo- 
cynth, may be given with great propriety, when there 
is considerable tumult of the general system. Saline 
draughts may be taken frequently in a state of efferves- 
cence, with the addition of a pill containing three grains 
of James's powder. But if there be present pain of the 
back, or of the head, or of the epigastrium, more urgent 
than these measures can effectually control, blood may 
be taken from the arm. 

It has often been said, that blood-letting, in the fever 
of invasion, interrupts the process of nature, repels the 
eruption, or so retards it, and so weakens the constitu- 
tion, that the due concoction of the pustules is never 
effected. It is undeniable that a man may be bled 
unnecessarily and too largely in small pox, but a mode- 
rate bleeding does no harm, and, if the fever runs high, 
often does great good. If the pulse be sharp, or very 
full, if the headache be severe, with accompanying epi- 
staxis, blood-letting is not only useful, but absolutely 
indispensable ; for the eruptive process is often impeded 
by the quantity of blood in the body, and the violence 
of the arterial excitement. Huxham justly said, " that 
you should bleed in the onset of these fevers, for the 



EMPLOYMENT OF BLOOD-LETTING. 99 

same reason that you draw off part of a fermenting 
liquor, — to prevent the splitting of the vessel. By 
drawing off some blood, you prevent the overdistending, 
inflaming, and rending the vessels of the human body." 

I can give you no rules as to the quantity of blood to 
be drawn. Consider the circumstances of each case, 
and be guided by them. Your object is to unload and 
relieve the lungs, the liver, or the brain. Whenever, 
therefore, these organs are gorged, and their functions 
impeded by a load of stagnant or inflamed blood — 
when intense headache, extreme irritability of the sto- 
mach, oppressed breathing, with a full laboring pulse, 
give evidence of such general or local congestion, draw 
blood, and let the quantity drawn be such as to relieve 
the urgent symptom. In some cases, when headache 
predominates, with suffusion of the eyes, leeches applied 
to the temples, afford all the relief which is required to 
take off the strain from the vessels. It is under these 
circumstances that active purgative pills, followed by a 
laxative draught, are so useful in diverting the fluids 
from the head and surface to a mucous membrane 
which is never implicated in the ordinary march of the 
disorder. 

Some writers, in their zeal for blood-letting, have 
tried to persuade themselves that it is the only measure 
which can be relied on to lessen confluence, and to 
prevent the development of pustules in the mucous 
membrane of the throat and trachea. This opinion is 
altogether erroneous. Bleeding has no effect on the 
quantity of eruption, whether cutaneous or mucous. 
The most confluent eruption has succeeded to the most 
vigorous employment of the lancet. To bleed, there- 
fore, merely because small pox is anticipated, with the 



100 TREATMENT DURING THE 

view, thereby, of preventing confluence, is uselessly to 
expend that power which will be required for the 
repair of injury to the surface. You will keep these 
general principles before you, and take care that in 
your efforts to diminish internal congestion you do not 
materially impair constitutional power. 

If the stomach, during the initiatory fever, remains 
very irritable, rejecting everything that is taken, even 
the saline effervescing draughts with laudanum, which 
you will naturally feel disposed to try, I recommend 
you to apply mustard poultices to the epigastrium and 
to the feet, and to promote eruption by the pediluvium. 

Again : if the circulation at this period be languid, 
if the pulse be small and feeble, the skin pale, and the 
extremities cold ; if the patient lies on his back, sunk 
and exhausted, let him have immediately warm brandy 
and water, cover him with bedclothes, apply mustard 
poultices to the centre and extremities of the circulat- 
ing system, and give thirty drops of laudanum, to be 
repeated in four hours, if necessary. This cordial 
plan of treatment must often be continued for several 
days, when the eruptive nisus is accompanied with 
depression, and nature appears so obviously unequal to 
the effort. 

While the pustules are in process of maturation, a 
variety of measures may be pursued, which, without 
interrupting the salutary and necessary process of pus- 
tulation, lessen the patient's sufferings, and prevent sub- 
sequent difficulties. 

If the eruption proceeds favorably, you would not do 
more than lessen thirst by saline draughts, and occa- 
sionally relieve the bowels by a dose of castor oil. If 



MATURATIVE STAGE. 101 

the maturation of a large crop of pustules excites much 
fever, it will be prudent to employ more active purga- 
tives, such as calomel with colocynth, the compound 
powder of jalap, or the infusion of senna with salts, all 
which cause a drain from the blood-vessels, and dimi- 
nish arterial action. Place the patient in a large and 
cool room, and cover him lightly with bedclothes. 
Remove all flannel coverings which may usually be 
worn next the skin. If the surface be very tender, 
apply to it some cooling lotion, such as the decoction 
of bran, with some spirit of rosemary. In all cases, 
even of moderate intensity, it is proper to cut the hair 
close, and so to maintain it during the whole course of 
the disease. The head is thus kept cool ; delirium is 
relieved or prevented ; the risk of cellular inflammation 
of the scalp diminished, cleanliness enforced, and an 
opportunity afforded for the employment of evaporating 
lotions, should more urgent symptoms arise. Opiates 
may be occasionally administered at bed-time, when 
there is much cuticular irritation, or great distress from 
want of sleep. 

The diet of the patient should consist of tea, bread 
and milk, arrow-root, rice milk, and roasted apples. 
Grapes, oranges, and ripe subacid fruits, are grateful to 
the patient, and useful adjuvants to the antiphlogistic 
remedies. Lemonade, apple water, tamarind water, 
toast water, and milk and water, must be the ordinary 
beverages. Sydenham permitted his patients to drink 
small beer — an indulgence which may still be granted. 
To that able physician we are indebted for this, the 
cooling system of treatment in small pox. How 
strongly does it contrast with the plan of stopping up 
every nook and cranny, by which a breath of fresh air 



102 TREATMENT OF THE PUSTULES. 

could gain admission, and drenching the unhappy suf- 
ferer with treacle posset and syrup of saffron ! 

One of the first objects which, in cases of more 
urgency, will attract your attention, is the condition of 
the throat. Gargles of infusum rosse compos, afford 
some relief. When the difficulty of swallowing is very 
great, and the tonsils much swollen, leeches applied to 
the throat, followed by poppy water fomentations, are 
serviceable. Under these circumstances, some physicians 
counsel you to apply to the throat, by means of a camel 
hair pencil, a strong solution of lunar caustic (twelve 
grains to the ounce), with the view of checking the 
advance of the mucous vesicles. I have not adopted 
this practice, from a conviction that it would not affect 
the tracheal inflammation, from which alone danger is 
to be apprehended. 

[Of late years, the solution of nitrate of silver has been applied to the 
posterior fauces and inside of the glottis, and even within the larynx, of 
much greater strength than that mentioned by our author ; and per- 
haps the introduction of a very strong solution of the crystallized salt 
(say 40 to 60 grains to Hj ; of distilled water) beyond the epiglottis, by 
means of a sponge attached to a piece of whalebone, or of steel properly 
curved at the end, might modify the condition of the mucous mem- 
brane of the larynx and trachea, and relieve the patient of a complication 
which is very apt to compromise his life. This application is said to 
have been attended with success. 

Chloruretted lotions are also highly recommended for the throat and 
nasal passages in severe cases of the confluent form.] 

Three measures have been pursued, having for their 
object to diminish action on the surface of the body 
during the maturative stage. The first was that of 
opening all the pustules, as fast as they ripen, by a gold 
needle. This was the Arabian practice ; but it is as 
useless as it is troublesome. The second is a modern 



TREATMENT OF THE PUSTULES. 103 

invention, that of applying lunar caustic to the pustules, 
so as to destroy them at an early period of their growth. 
As a partial application — say, to vesicles forming near 
the eye, — I can recommend this measure ; hut I cannot 
advise you to employ it to any large surface covered 
with confluent or semi-confluent vesicles. The pain 
which such an application occasions is very great, and 
must, of itself, add largely to the danger of the patient. 
In the distinct form of small pox, the remedy would be 
worse than the disease. 

The latest mode of treating the surface during the 
maturative stage of small pox is that of applying mer- 
curial plasters, containing calomel or corrosive muriate 
of mercury, or covering the whole surface with mer- 
curial ointment. In the French hospitals at the present 
time, the latter mode is in fashion. The reports which 
have reached me of its success, however, are not very 
flattering. I have seen all three plans fairly tried at 
the Small Pox Hospital. The ointment and calomel 
plasters were inefficient. The plaster of corrosive 
sublimate converted a mass of confluent vesicles into 
one painful and extensive blister, but I am still to learn 
what benefit the patient derived from the change. 

Throughout the whole period of maturation, you will 
look carefully to the state of the internal organs. In a 
very large proportion of cases these are unaffected, but 
bronchial inflammation, and even pneumonia, may 
supervene, which yoti will meet by the usual remedies. 
In cases of delirium, carefully restrain the patient, 
exhibit active purgatives, and wait until the fall matura- 
tion of the pustules shall have relieved the tension within 
the head. 

The petechial form of small pox admits of no essen- 



104 MANAGEMENT OF THE PETECHIAL FORM. 

tial relief from medicine. I can scarcely say that we 
can palliate even the most pressing symptoms. Active 
purgatives are inadmissible. I have tried the influence 
of mercury, but it is of no value here. The loss of a 
little blood from the arm has appeared to me more 
effectual than any other measure. The infusion of 
roses and acid is prescribed more in conformity with 
general usage, than with a view to any real benefit 
The citrate of ammonia in effervescence, with port 
wine and brandy, must be given when the powers of 
life appear to fail, but the hsemorrhagic diathesis is often 
accompanied by a hot skin and an excited circulation. 

[Cases of this form of disease occasionally recover under the free use 
of stimulants, when the haemorrhage from internal organs is not very 
profuse, nor very protracted. Some sink at once without haemorrhage, 
and without reaction enough to develope the variolous eruption. 

In other cases, where petechias exist, or spots of purpura even of con- 
siderable extent, and the prostration is not great, and no haemorrhage 
takes place from internal organs, the prognosis is very much less 
unfavorable. I have seen varioloid with this complication pass favor- 
ably through its stages without interruption, the purpura disappearing 
in the course of a few days.] 

The decline of the mild form of small pox requires 
little else than attention to the state of the bowels, and 
care lest too great indulgence of the appetite should 
light up feverish excitement. A warm bath is always 
advisable before the patient mixes again in society. 
Vapor baths, when they can be procured, are very ser- 
viceable in promoting a more healthy state of the 
surface. 

The difficulties in the management of small pox 
begin with the setting in of secondary fever. The com- 
plications are then so numerous, the struggle between 



TREATMENT IN SECONDARY FEVER. 105 

the disease and the constitution so close, excitement 
and exhaustion tread so near upon each other, that it is 
scarcely possible to assist you with any rules admitting 
of precise application. I shall satisfy myself, therefore, 
with some remarks on the chief points which will 
attract your notice, first treating of internal, and then of 
external remedies. 

One of, the most remarkable disputes which ever 
arose in physic was that regarding the propriety of 
using purgatives during the secondary fever of small 
pox. Sydendam, with all his boldness, never wholly 
divested himself of the early prejudices which the Ara- 
bians had inculcated against purgatives in small pox. 
Morton inveighed bitterly against their use, while Dr. 
Friend, with the true spirit of a reformer, advocated 
their free employment, especially during the secondary 
fever. 

In 1708 a young nobleman took confluent small pox. 
Dr. Friend was called in with two physicians of the old 
school. The arguments in the consulting room were 
long and stormy. The patient died, in spite of the 
purgatives which Dr. Friend's pertinacity had at length 
induced his colleagues to agree to. A paper war suc- 
ceeded, and from words the parties came to blows. In 
June, 1719, Dr. Mead and Dr. Woodward met in 
Cheapside, drew their swords, and, after a few passes, 
Mead came off victorious. This display effectually 
settled the dispute, and purgatives are now as freely 
employed in the secondary fever of small pox as in 
ague or in typhus. They are of the greatest service 
when the skin is hot and dry, when scarlatinal rash 
covers the body, or innumerable abscesses give evidence 
of the excited state of the cutaneous vessels. 



106 TREATMENT IN SECONDARY FEVER. 

Profuse pustulation demands that the strength of the 
system should be supported by nourishing diet, an allow- 
ance of ale, porter, or wine, and cordial medicines. In 
the great depression which sometimes succeeds the 
destruction of large portions of the surface, when sub- 
sultus tendinum, general tremors, a feeble pulse, and a 
dry tongue, attract observation, wine mnst be liberally 
administered, with beef-tea, and a mixture containing 
nitric sether and the carbonate of ammonia in camphor 
julep. 

In the progress of secondary fever we sometimes 
witness the access of very acute seizures, such as phre- 
nitis, apoplexy, peripneumony, and pleurisy. Blood 
may be taken freely from the arm in many of these 
cases. In others, leeches afford the only palliative 
which medicine can suggest. Blisters are, from the 
condition of the surface, seldom, if ever, applicable. 
Syncope, palpitation, cold extremities, and other evi- 
dences of deficient power, and cardiac implication, 
demand the administration of wine and ether. 

Erysipelas, succeeding small pox, must be treated with 
reference to the accompanying state of the circulation. 
For the most part, it is best combated by purgatives 
and saline medicines. Sometimes, wine and the decoc- 
tion of bark are indicated. Ophthalmia is one of the 
most serious evils which the secondary fever of small 
pox gives rise to. The loss of blood, which the inten- 
sity of the symptoms appears to warrant, would be 
followed by great and perhaps irremediable exhaustion. 
In some cases, therefore, the eye must be sacrificed to 
save the patient's life. Leeches, cupping-glasses to the 
temples, active aperients, calomel, pushed so as to affect 
the mouth, with warm fomentations, are the remedies 



EXTERNAL TREATMENT. 107 

on which you must mainly rely. In a more chronic 
form of the complaint, blisters to the temples afford very 
decided benefit. 

When small pox has called into activity the dormant 
seeds of scrofula, when irritable sores, irritable ophthal- 
mia, enlarged joints, and ecthymatous pustulation, com- 
biue to weaken an already debilitated frame, your 
utmost efforts will be called into requisition, but often 
with doubtful success. The best remedies are occa- 
sional warm baths, a course of sarsaparilla, and mode- 
rate doses of blue pill and rhubarb, to insure due action 
of the liver. The remedy of most unquestionable 
efficacy is change of air. It imparts tone to the lan- 
guid vessels of the surface, converts an ecthymatous 
surface into healthy granulations, improves the appe- 
tite, and gives tone to the retina. The influence of an 
altered air on the diseased actions of the body is better 
displayed in the sequelae of small pox than in any other 
known disorder. 

A few words on external treatment will conclude this 
division of the subject. When pustulation is profuse, 
benefit is obtained by covering the surface liberally with 
some simple dry powder. Starch powder, hair powder 
(well dried), and the powder of calamine, are alike 
available for this purpose. Cold cream, and mild 
unguents, such as the ung. cetacei, with a proportion of 
oxide of bismuth, are useful when there is much cuta- 
neous irritation with a dry surface. Fomentations and 
poultices are the only local means of treating those 
abscesses and erythematous inflammations which so 
harass the patient and so fearfully peril life in the later 
periods of secondary fever. 

All the attempts made by the use of masks to prevent 



108 INOCULATION IN SMALL POX. 

pitting, end in disappointment. The only effectual 
means of lessening such disfigurement are those which 
allay cutaneous action. Purgative medicines, low diet, 
and free exposure of the face to a cool air, are the sole 
measures on which your reliance ought to be placed. 

[Other means besides those mentioned in the text have been used for 
preventing pitting, either by causing the abortion of the pustules in their 
forming stage, or drying them up after maturation, and upon authority 
which would seem to render them worthy of notice. 

For the different* applications which have been recommended, the 
manner of using them, their modus operandi, &c, see Appendix F.] 

Inoculation having been abolished by act of parlia- 
ment in this country, any lengthened details concerning 
it would of course be superfluous, and very much out of 
place. Nevertheless, a measure so remarkable in its 
consequences, and which, for the better part of a cen- 
tury, was the object of general attention, to which 
every individual in this kingdom above the age of 
forty-two now trusts as his security from a loathsome 
pestilence, must not be passed over without a short 
comment. 

Inoculation is performed by introducing into the arm, 
at the insertion of the deltoid, by means of a lancet, a 
minute portion of variolous matter. The thin lymph 
of a fifth-day vesicle is to be preferred to the well-con- 
cocted purulent matter of the eighth day, but both are 
efficient. One incision only is to be made. A minute 
orange-colored spot is perceptible, by aid of the micro- 
scope, on the second day ; on the third or fourth day a 
sensation of pricking is experienced in the part. The 
punctured point is hard, and a minute vesicle, whose 
centre is depressed, may be observed, surmounting an 
inflamed base. On the fifth day, the vesicle is well 



MODE OF PRACTICE. 109 

developed, and the areola commences. On the sixth 
day, the patient feels stiffness in the axilla, with pain. 
The inoculated part has become a hard and inflamed 
phlegmon. The subjacent cellular membrane has 
become involved in the inflammatory action. On the 
evening of the seventh, or early on the eighth day, 
rigors, headache, a fit of syncope, vomiting, an offensive 
state of the breath, alternate heats and chills, languor, 
lassitude, or, in the child, an epileptic paroxysm, 
announce the setting in of fever. The constitution 
has taken alarm, and sympathizes with the progress of 
the local disorder. 

On the appearance of febrile symptoms, the inflam- 
mation of the arm spreads rapidly. An areola of 
irregular shape is soon completed, which displays within 
it minute confluent vesicles. On the tenth day, the 
arm is hard, tense, shining, and very red. The pustule 
discharges copiously, and ulceration has evidently pene- 
trated the whole depth of the corion. 

On the eighth day, spots of variolous eruption show 
themselves in various, and often in the most distant, 
parts of the body. In a very large proportion of cases, 
the eruption is distinct and moderate. Two hundred 
vesicles are counted a full crop. Sometimes not more 
than two or three papulae can be discovered, which 
perhaps shrivel and dry up without going through the 
regular process of maturation. At other times, the 
eruption is full and semi-confluent, passing through all 
the stages of maturation, and scabbing, and cicatriza- 
tion, with as much perfection as the casual disease can 
display. Between these extremes every possible variety 
may be observed. The truly confluent eruption with 
affection of the mucous membranes is very rare, and 



110 MODE OF PRACTICE. 

that implication of the fluids and of the nervous system, 
which together constitute the extreme of variolous 
malignity, is nearly, if not entirely unknown. Secon- 
dary fever, therefore, is not common, at least in any 
intensity. 

The rules laid down for the safe conduct of inocula- 
tion were principally the following : — It should be per- 
formed exclusively in persons free from actual bodily 
disease, and neither plethoric nor scrofulous. It may 
be safely practised at all ages, beginning at the third 
month. It is improper to inoculate during pregnancy, 
on account of the danger to the child in utero. It may 
be practised in all seasons and in all climates. It 
proved not less successful among the negroes in Jamaica, 
than in the inhabitants of St. Petersburgh. Perfect 
health being the best condition for receiving and safely 
eliminating the poison, everything that tends to dimi- 
nish plethora, to lessen cutaneous action, to render the 
bowels free, to preserve the blood in a cool, pure, and 
normal condition, was found useful. Laxative medi- 
cine, a moderate diet, abstinence from all fermented and 
spirituous liquors, cool chambers, gentle exercise in the 
open air, light clothing, — all contributed, in their several 
degrees, to the successful result. The antimonial and 
mercurial medicines, which the Suttons laid much stress 
upon, were useful only to secure the co-operation of 
the patient in matters of more necessity, especially diet 
and exposure to the open air. 

You will naturally wish to know what was the prac- 
tical result of inoculation. I will tell you in a few 
words. Its influence in lessening the mortality of small 
pox was something quite extraordinary, and scarcely 
credible. With ordinary precautions in the choice and 



RESULTS OF INOCULATION. Ill 

preparation of subjects, not more than one in live hun- 
dred eases will terminate unfavorably. The ill success 
which attended the early inoculations, between the 
years 1722 and 1730, arose entirely from bad manage- 
ment, from the most culpable negligence in the choice 
of subjects, and an utter ignorance of all the principles 
by which the practice of inoculation should be governed. 
Had not the discovery of Jenner interfered to interrupt 
its extension and improvement, inoculation would have 
continued to this day increasing yearly in popularity. 
It cannot be doubted that improvements in medical 
science generally would have shed additional lustre on 
this practice. 

Since the introduction of vaccination, it has been the 
fashion to decry inoculation, and to impute to it mis- 
chief of which it was not guilty. The great objection 
made to inoculation, and that which recently induced 
Parliament to abolish it altogether, under heavy penal- 
ties, was, that it disseminated the virus, and multiplied 
the foci of contagion. Dr. Watkinson and Dr. 
Schwenke, in 1777, and more recently, Dr. Adams, 
broke the force of this argument, by pointing out how 
important a part epidemic influence plays in the diffu- 
sion of variola. Had they lived in our times, how 
strongly would they have fortified their arguments ! 
We saw, in 1838, an epidemic small pox raging in 
London, where inoculation had long been discontinued. 
The admissions into the Small Pox Hospital in that 
year exceeded those of 1781 and of 1796. Inoculation 
was abolished throughout England and Wales in 1840, 
and the act has been most rigidly enforced ; yet, during 
the two last years, small pox has visited every county 
of England. 



112 RESULTS OF INOCULATION. 

Sir Gilbert Blane has attempted to prove by statistics 
the evils of inoculation. He has shown that the pro- 
portion which the mortality by small pox in London 
bore to the general mortality, increased during the last 
century from 78 to 94 per thousand, but many circum- 
stances must receive attention before we are justified in 
drawing conclusions from this fact. The population 
increased prodigiously in the interval, more indeed than 
would suffice to explain the increased mortality by small 
pox. But, further, the general mortality diminished. 
Consequently, though the actual mortality by small pox 
had remained stationary and uninfluenced by popula- 
tion, its ratio to the total mortality would appear to 
augment. Thirdly, Dr. Adams has shown that a cor- 
respondent increase took place in scarlet fever and 
hooping cough, which are not communicable by inocu- 
lation. Lastly, a different mode of calculation would 
exhibit a very different result. The sophism consists 
in arranging your figures so as to include or exclude 
years of epidemic prevalence. If, for instance, we 
divide the last ninety years of the 18th century into 
three periods, we shall find that the recorded deaths by 
small pox were as follows: — 1711 to 1740 (when there 
was no inoculation), 65,383; 1741 to 1770 (when 
inoculation was coming into general use), 63,308 ; 1771 
to 1800 (when inoculation was almost universal), the 
deaths were only 57,268 : so that, by this showing, 
inoculation diminished the mortality by 8115 lives! 

Statistics are very useful, and deservedly carry great 
weight with them ; but they may be enlisted, with a 
little management, on both sides of an argument. 

[For remarks on the influence of inoculation upon mortality, see 
Appendix G.] 



ABOLITION OF INOCULATION. 113 

One subject only remains for our consideration, and 
that is, the question whether any circumstances would 
still warrant us in recommending inoculation on scien- 
tific principles ? Concurring most cordially in opinion 
that the practice of inoculation by unqualified persons 
ought to have been put down (not in 1840, but forty 
years before that) by stringent legislative enactments, I 
still remain of opinion, that under several circumstances 
it is the duty of a medical man to recommend inocula- 
tion. These circumstances do not, indeed, often occur; 
but the legislature would hardly wish to control and 
fetter, even in a single case, the deliberate judgment of 
a physician, acting for the benefit of his patient. I will 
name to you four of these cases: — 1. When a person 
has been found, from peculiarity of habit, unsusceptible 
of vaccination. 2. When new sources of vaccine 
lymph are introduced, and it becomes of importance to 
ascertain that the new virus is efficient. 3. When 
young persons (between the ages of ten and twenty), 
vaccinated in early life, are proceeding as cadets to 
India. 4. When small pox unexpectedly breaks out in 
a country district, at a time when (even with the 
facilities of a penny post) vaccine virus is not to be 
obtained. 

Other cases, equally strong, might be put ; but what 
I have said will probably suffice to show that a clause 
(duly guarded against abuse) permitting qualified medi- 
cal practitioners to inoculate under circumstances of 
urgency, would have been an useful addition to the 
Vaccination Extension Bill. That it was not so added 
was no fault of mine. 



LECTURE VI. 

RUBEOLA, OR MEASLES. 

Characters of rubeola. Its early history. Its supposed identity with small 
pox and scarlatina. Incubative stage. Characters of the initiatory fever. 
Rubeola sine catarrho. Maturation of measles. Exacerbation of the 
rash. Decline of measles. Rubeolous pneumonia. Other sequelae of 
measles. Abdominal inflammation. Malignant measles. Appearances 
on dissection. Cancrum oris. Prognosis in measles. Diagnosis. Patho- 
logy of measles. Recurrence of measles. Inoculation of measles. 
Statistics of measles. Treatment during the early stage. Employment 
of blood-letting in the pneumonic complication. Treatment of malignant 
measles. Treatment of the several sequelae of measles. 

Rubeola, or measles, the rongeole of the French, the 
morbilli of Sydenham and other old authors, is an exan- 
thematous disease, characterized by the following 
symptoms : — A fever, with catarrhal implication, which, 
at the end of seventy-two hours, throws out an abundant 
eruption, consisting of minute conflueut papulae, slightly 
elevated above the surface of the skin, and subsiding in 
three, or at furthest, in four days ; the catarrhal symp- 
toms, in all normal cases, declining on the appearance 
of eruption, but sometimes, especially in severe and 
irregular cases, continuing, or merging in those of pneu- 
monia. The disorder, for the most part, occurs to all 
mankind once in the course of life ; but having been 
undergone, the constitution remains for ever after 
unsusceptible of the same disease. 

No complaint possessing these very striking features 
is to be found recorded in the writings of any Greek or 
Roman author. Dr. Willan (in his Miscellaneous 
Works, 1821) struggles hard to prove that such a dis- 



HISTORY OF RUBEOLA. 115 

ease was known to them ; but his researches have 
made no converts. The opinions of Friend and Mead 
are still adopted, and we are constrained to believe that 
the measles is a disease of comparatively modern origin. 

All our best medical historians concur in the belief 
that measles began to spread through the world about 
the same time as small pox, and that it had its origin in 
the same countries whence the variolous miasm arose. 
The shores of the Red Sea, the coasts of Arabia and 
Abyssinia, first experienced the assaults of this malady, 
and probably about the fifth or sixth century. Constan- 
tine Africanus dates the origin of measles two or three 
centuries after small pox; but I know not on what 
grounds. The first distinct allusion to measles is found 
in the writings of Rhazes, the Arabian physician already 
mentioned as the auctor princeps on small pox. Rhazes 
is supposed to have flourished early in the tenth century 
(910). His successors, Hali Abbas and Avicenna, the 
two most distinguished authors of the Arabian school, 
described measles under its Arabic name, Hasba, or Al 
hasbet. The term rubeola was introduced subsequently 
by the Latin translators of Hali Abbas, and by some 
appears to have been appropriated to that variety of 
exanthema now called scarlatina. 

The term morbilli was employed from a very distant 
period also, and seems to have included every variety of 
exanthema, accompanied by efflorescence. In this sense 
morbilli was used by Morton at the close of the seven- 
teenth century. Sydenham carefully restricted the term 
morbilli to measles. 

It is not only curious but instructive to trace the 
gradual expansion of men's minds in the diagnosis of 
the exanthemata. All the Arabian authors were im- 



116 IDENTITY OF MEASLES AND SCARLATINA. 

pressed with the belief that small pox and measles 
were pathologically associated. Avicenna pronounced 
measles to be a bilious small pox. In 1640, Daniel 
Sennertus proposed as a subject of inquiry, why the 
disease in some constitutions assumed the form of small 
pox, and in others, that of measles. 

Diemerbroeek, in a posthumous work, published in 
1687, asserts that the two diseases are only different 
degrees of the same malady. " Differunt morbilli a 
variolis accidentaliter, vel quoad majus et minus." 
" The matter by which measles is generated," says he, 
" is not so thick as in the case of small pox. It is 
drier, and somewhat choleric." (Choler, or bile, was 
the dry humor) This author held that such as had 
had small pox were generally exempt from the measles, 
" though, 'tis true they can challenge no absolute immu- 
nity. Therefore," he adds, " measles is chiefly met with 
in young persons." 

Sydenham, who was the contemporary of Diemer- 
broeck, and a much better physician, devoted much of 
his attention to measles. He described with great 
accuracy the epidemics of 1670-74, and his opinions 
concerning measles display singular acuteness. He 
permanently separated small pox from measles, which 
was a great step in pathology. The belief in the 
identity of measles and scarlatina, however, still pre- 
vailed. Twenty years after the time of Sydenham, 
Morton viewed measles and scarlatina as the product of 
the same miasm, and averred that they stood to each 
other in the same relation as the distinct and confluent 
small pox. Hence, by many authors of that age scarla- 
tina w 7 as called morbilli confluentes. Even so recently 
as 1779, Dr. Withering speaks of measles as being 



INCUBATIVE STAGE. 117 

nearly allied to scarlatina. By this time, however, 
physicians had become sensible that (he two diseases 
arose from different miasms. This conviction was 
forced upon them by observing that patients who had 
gone through measles were equally with others subject 
to scarlatina. 

Having brought down the history of measles to out- 
own time, I proceed to describe to you its phenomena. 
I shall first make you acquainted with measles as it 
occurs in healthy habits, and in its simplest and most 
usual form. This constitutes the morbilli regular es of 
Sydenham. 

Measles is the product of a miasm or morbid poison, 
which in this country is invariably received by the mode 
of infection. It has, of course, its breeding or incubative 
period. The term latent period is improper, because 
the miasm, often from the very first, gives evidence of 
its activity. Sometimes the entire incubative stage is 
marked by languor, lassitude, a sense of mal-aise (or 
dis-ease), and occasionally a characteristic symptom, 
such as cough. I once attended a lady, who for a fort- 
night had a cough which baffled us all, but terminated 
at length by a copious eruption of measles. At other 
times, the first eight or ten days of incubation are passed 
without any sign of ill health. 

The early authors, biassed, no doubt, by their preju- 
dices in favor of exanthematic identity, taught that the 
initiatory symptoms of measles were the same as those 
of small pox. This, as a general rule, cannot be admit- 
ted. With regard to the duration of such symptoms, 
authors are more agreed. Heberden says that from ten 
to fourteen, Burns that from twelve to fourteen days, 



118 CHARACTER OF THE 

usually elapse from exposure to contagion to the appear- 
ance of rash. Dr. Willan considers sixteen days as the 
extreme limit. The first week being usually passed 
without symptoms, the child (for the greater proportion 
of your measly patients will be children under seven 
years of age) then droops. Catarrhal symptoms super- 
vene. Chills, flushes, disturbed nights, some degree of 
delirium or drowsiness during the day, with weight on 
the forehead, are then observable. Pain of the back is 
a frequent symptom. The pulse is quick. The tongue 
is white. 

From the occurrence of rigors to the appearance of 
rash, seventy-two hours elapse. The initiatory fever of 
measles affects the quartan type. Two complete days 
intervene. The rash comes out on the fourth day from 
the setting in of fever, and the eleventh or twelfth from 
the imbibition of the poison. The following cases will 
illustrate the ordinary process of incubation, and the 
anomalies occasionally witnessed : — 

Case 1. — Miss M. D., aged seven years, residing in a 
retired situation at Woodgreen, was brought to London 
on Tuesday, January 10, 1843, to attend a juvenile 
party. One of the children whom she there met, sick- 
ened for the measles on the following day, and before 
the end of the week two others of the party had been 
seized. On the morning of Tuesday, January 24, 
being fourteen days from exposure, Miss M. D. began 
to complain of languor, headache, sneezing, and cough. 
The eyes were suffused. On Friday, the 27th, measles 
appeared on the face. The full incubation extended 
here to eighteen days. This young lady was attended 
by Dr. Munk, of Finsbury-place. 

Case 2.— On Tuesday, February 14, 1831, Mrs. D., 



INITIATORY FEVER. 119 

aged 26, went to Camberwell in a hackney coach. The 
coachman appeared ill as he let down the steps. At 
dinner, Mrs. D. fell sick and poorly, and so continued 
all the rest of the week. On Tuesday, February 21 
(eighth day), she complained of rigor and violent pain 
of the back. Her husband, a surgeon, imagined she 
was passing a calculus. This pain continued all 
Wednesday and Thursday. On Thursday, the 23d 
(tenth day from exposure), I first saw her. The symp- 
toms were backache and headache. The eyes were 
suffused ; the pulse 130. On Friday, the 24th, at ten 
a.m., seventy-two hours exactly from the first rigor, 
measles appeared. Eleven days of incubation. 

Case 3. — Eliza Finch, aged four months, residing at 
Pentonvdlle, was vaccinated by me at the Small Pox 
Hospital, May 15, 1832. May 17, the child began to 
droop. Bilious vomiting, very severe, with drowsiness, 
succeeded. Much blood passed by stool. The head 
was very hot. Vomiting continued all that and the 
four following days. It ceased on the 22 d. On the 
24th the other febrile symptoms yielded a little. On 
the 25th (nine days from the invasion of symptoms, and 
eleven from the probable reception of the germ), measles 
appeared, and went through its course regularly. 

[Of 38 patients in the wards of MM. Rilliet and Barthez, the eruption 
appeared in four instances, in from 4 to 5 days ; in eight, from 9 to 
13 days; in twenty, from 15 to 25 days; and in six, from 28 to 58 
days. 

In an epidemic in the Necker Hospital (Paris), in 1843, in the service 
of M. Bouchut, the period of incubation varied from 12 to 29 days- 
This period varies with the natural predisposition of the patient as well 
as with accidental causes. {Med. Chir. Rev., Oct. 1845, p. 40G.) 

With regard to the last six cases mentioned by MM. Rilliet & B., 
the question may perhaps be asked, whether they were not rather cases 



120 INITIATORY FEVER. 

of more recent infection from fomites or fresh exposure than instances of 
prolonged incubation.] 

The leading features of the initiatory fever of measles 
are, I have said, catarrhal. I must describe them to 
you more in detail. 

1. There is sneezing. I have seen both adults and 
children sneezing every five minutes, and really ex- 
hausted by it. In the case of Robert Woodland, whom 
I attended in June, 1830, the sneezing ended in epi- 
staxis. You know that sneezing indicates a gorged and 
irritable state of the Schneiderian membrane. 

2. The eyes are red and watery. There is epiphora, 
the great diagnostic on which nurses are wont to rely. 
While the measles are breeding, you will be sure to find 
the window-blinds down, and the curtains of the bed 
close drawn. The slightest ray of light is painful. 
There is irritability of the retina, sometimes attended 
by inflammation of the conjunctival membrane. 

3. There is a loud, dry, hollow cough (tussis sicca). 
The violence of this cough, on some occasions, will 
astonish you, as it did me many years ago, while attend- 
ing a young Irishman, Mr. Webb, at Islington. It was 
not only loud, but incessant. The trachea and bronchi 
participate in the same kind of action (whatever be its 
nature) which takes place in the nose and eyes. 

4. There is hoarseness {I'aucedd). The larynx is 
also implicated. In fact, the mucous structures gene- 
rally of the head and chest receive the first impetus of 
the poison. We are not justified in saying that the 
action developed in them is inflammation. The mem- 
branes are probably only in a state of congestion with 
increased irritability — a state which plethora, bad 



RUBEOLA SINE CATARRHO. 121 

management, a cold season, or a bad habit of body, 
may convert into inflammation. 

Ever siuce measles was separated from scarlatina, 
authors have described an exanthematic disorder, allied 
in aspect to rubeola, but not exhibiting any initiatory 
catarrhal symptoms. Such a complaint has been called 
rubeola sine catarrho, or incocta. By some it is called 
the bastard, spurious, or imperfect measles. Much 
attention has been paid to it in Germany. i)x. Willan's 
opinions on it seem to guide the pathologists of this 
country. He considered it as a species of measles, 
arising from the true rubeolous poison ; but he added, 
" persons receiving the miasm in this form are pecu- 
liarly liable to a second attack of measles." 

This last admission seems to me nearly decisive of 
the question. I believe that by far the larger proportion 
of such cases are cases of febrile lichen. I should be 
inclined to lay all the stress on the duration of the ini- 
tiatory feve:. If this extends to 72 hours, the disorder 
is measles, whether catarrhal symptoms be present or 
not. On the other hand, if a rash of a rubeolous charac- 
ter succeeds a brief period of febrile commotion (24 or 
48 hours), the disease is not measles, and the child will 
fall into true measles at some subsequent period of its 
life. It is worthy of note, that no author who has 
treated of this bastard or imperfect measles mentions it 
as occurring after the true measles. 

[The cases which we have much more frequently seen confounded 
with measles, and which probably constitute the largest share of " rube- 
ola sine catarrho," have been those of Roseola, between the cutnneous 
developments of which and of Rubeola there is often great resemblance. 

The question is often asked, whether measles can exist without the 
eruption. 



122 SEAT OF ERUPTION. 

Dr. Rush mentions cases of persons who, in 1*789, had fever, cough, 
and all the usual symptoms of measles, except a general eruption, some 
having a trifling efflorescence about the neck and breast, and Webster 
says [History of Epidemics, vol. ii. p. 238) that the same thing hap- 
pened in 1773 and 1783. 

Rayer (Diseases of Skin, vol. i. p. 177) quotes M. Guersent as author- 
ity for the occasional occurrence of cases presenting all the symptoms of 
measles without the eruption, but says that he has never met with 
instances of the kind, although his attention has been directed to the 
subject for several years part. 

In an epidemic of measles in Paris in March, 1850, well authenticated 
cases of this kind appeared. The children for several days presented all 
the premonitory symptoms of an acute attack of measles. In a certain 
number, the disease appeared and followed its usual course ; in others, 
however, it appeared to be determined to the air passages, some pre- 
senting unequivocal spots of measles on the neck and chest, which very 
soon disappeared, while the lungs became engorged. (London Med. 
Gaz., June, 1850, p. 572.)] 

The appearance of measly eruption is very charac- 
teristic. It comes forth in a full crop, and rapidly 
reaches its climax. In regular measles, the face is 
always first affected. 

[We have sometimes first detected the eruption of measles directly 
behind the ears, and at other times it will be first found on the back of 
the neck. 

It is said by some that the eruption of measles, as is true of that of 
small pox and of scarlet fever, can always be detected on the mucous 
membrane covering the palate and posterior fauces several hours sooner 
than on any other part. A distinguished medical friend in this city in- 
forms me that he has often made a diagnosis of measles twenty -four 
hours before the eruption appeared on the skin, by an eruption on the 
roof of the mouth and soft palate, more especially on the former, to see 
which the head must be held back. 

This affection of the mucous membranes of the mouth and palate, is 
but a part of the general affection of the throat, nasal, and bronchial 
passages, on which the coryza and hoarseness depend, and we should 
anticipate great congestion of these surfaces, with bright redness, even if 
the distinct eruption cannot always be found. 



MATURATION OF MEASLES. 123 

It ought perhaps to be mentioned in this connexion, that a similar 
redness in these parts sometimes occurs in Roseola.] 

When closely examined, the eruption is found to con- 
sist of a congeries of minute papulae, close set, or con- 
fluent, and for a short time perceptibly elevated above 
the level of the surrounding skin. This elevation, or 
roughness, is most perceptible on the forehead. On 
the limbs it is scarcely to be detected. The color of 
the measly eruption is a dingy red, very different from 
the bright scarlet hue of its rival. Hence the French 
name Rougeole, or fievre rouge. The difference in 
color may easily be traced to the tracheal and bronchial 
complication so generally present in measles, which, 
extending partially into the substance of the lungs, 
gives a venous character to the blood. In scarlet fever, 
on the other hand, the lungs are unaffected, while there 
is intense arterial action. The eruption, therefore, par- 
takes strongly of the character of arterial blood. 

The development of eruption is often accompanied 
with a very moist state of the surface. This is the 
normal mode of development, and of course always to 
be desired. Few, if any cases, that begin thus, end 
unfavorably. The same thing is true of all exanthema- 
tic disorders. In a hot and dry state of the surface, 
eruption is difficult, partial, and imperfect. 

By Willan and others, the patches of measly eruption 
are said to assume a crescentic arrangement. I have 
often been disappointed in my search for this appear- 
ance, and am inclined to think there is some little fancy 
called into play in this description. 

On the second day of eruption (the fifth from the 
occurrence of rigors), the eyelids often swell, from the 
extension of cutaneous action to the subjacent cellular 



124 



EXACERBATION OF THE RASH. 



tissue. Although I have never seen such a thing, I 
have jet heard of children blinded by measles during 
the space of four days. The progress of measly erup- 
tion, in all normal cases, is steadily from above down- 
wards. On the second day of eruption, the trunk and 
upper extremities are occupied. On the third, it has 
extended to the lower extremities, by which time it has 
nearly disappeared from the face. On the sixth day, it 
has faded over the whole surface. 

[Barthez & Rilliet say that there is a period of increase in measles 
which lasts one or two days, and a period of decrease which lasts three 
to fifteen days, the eruption being stationary but a very short time 
(Mai. des enfants). The eruption has most commonly disappeared at the 
end of six days ; but not unfrequently remains until the seventh, and 
sometimes even lingers to the ninth or tenth day.] 

Some modifications occur even in the most regular 
measles. One of the most familiar is an abundant crop 
of miliary vesicles on the arms and trunk, filled with a 
thin transparent lymph, and of such size and distinct- 
ness as to create a suspicion of the disease being small 
pox. We may well believe that the frequency of this 
event led originally to the idea of identity. Measles of 
this kind has been called rubeola variolodes, or the 
nirles. Pathologists have reasoned themselves into the 
belief that this symptom is owing to a peculiarly inflam- 
matory state of the cutaneous capillaries, but it will 
be observed in mild cases, unaccompanied with high 
fever. 

Another anomaly merits notice, the reappearance or 
exacerbation of the rash after having reached or passed 
its regular crisis. Dr. Willan first noticed this circum- 
stance. He records two cases of the kind in his " Re- 
ports of the Diseases of London."' Frank, of Vienna, 



DECLINE OF MEASLES. 125 

has observed the same thing. Dr. Conolly recites a 
like case, where the renewed eruption was so copious 
and intense on the face as to make it impossible to 
recognise the features. Some years ago, a case in 
every respect similar occurred at Brompton to Dr. Sey- 
mour and Mr. Chinnock. Ten days elapsed in this 
instance before the renewal of the exanthematic action. 

By most authors, it is stated that the decline of 
measles is attended with desquamation of the cuticle, 
the scales being so minute that the body appears as if 
sprinkled over with fine bran. That this is perceived 
in some cases is unquestionable, but in many no such 
destruction of cuticle takes place. The cause of 
desquamation is the intense heat of skin which dries up 
and kills the minute fibrils connecting the cuticle with 
the corion. Desquamation does not form that striking 
feature of measles which it does of scarlatina and erysi- 
pelas, because the heat of surface seldom attains the 
requisite degree of intensity. 

In the perfectly regular measles, the cough, hoarse- 
ness, and other mucous symptoms, begin to abate on the 
first appearance of eruption. I have seen the cough cease 
instantly, as if by magic. Let me pause for a moment 
to illustrate, by this means, the mode in which blisters 
relieve a teasing winter cough. The principle is exactly 
the same. The skin and tracheal membrane are analo- 
gous or homophysic structures, and irritation set up in 
the one, whether by nature or by art, relieves irritation 
(and even inflammation) in the other. 

The sequelae, or dregs, of measles require from you 
as much study as the earlier periods of the complaint. 
I have described the normal progress of measles in per- 
fectly healthy subjects. I am now to trace its effects 



126 RUBEOLOUS PNEUMONIA. 

on weakened and scrofulous constitutions. Generally, 
in such habits something occurs early to give cause of 
uneasiness. The initiatory fever has been severe. The 
eruption has been retarded twelve or twenty-four hours. 
It has receded and returned. Epistaxis, or an epileptic 
fit, or diarrhoea, has occurred to interrupt the normal 
course of the disease, and warn you of impending 
danger. Above all, in such constitutions the catarrhal 
symptoms do not subside on the outbreak of eruption. 
The cough continues. The child becomes restless. 
Careful observation detects dyspnoea. The stethoscope 
gives signs of impeded respiration. Instead of the 
febrile symptoms subsiding on the sixth day, and the 
child expressing its desire to get up and have its toys, 
the little sufferer continues to droop. Its hands are 
hot ; its nights unquiet. It is thirsty, and the urine is 
scanty. Secondary fever has set in. 

During the progress of secondary fever, inflammatory 
action, sometimes acute, but more commonly of a lower 
subacute kind, arises in one or more of the structures 
which were the seats of primary irritation — namely, the 
eyes, the glands of the neck, the larynx, the trachea, or 
the lungs. Scrofulous ophthalmia, scrofulous enlarge- 
ments of the glands of the neck, with succeeding ulcer- 
ation, laryngitis, croup, but above all, pneumonia, are 
the sequela of measles. Of the laryngeal and croupy 
affections I have nothing to offer differing from the usual 
phenomena of those disorders arising idiopathically. 
The danger is alike in both cases. Measly pneumonia, 
from its extreme frequency and frightful devastations, 
deserves a closer attention. 

Pneumonic complication occurs both in the progress 
of the eruption and during its decline. It is a slow, 



RUBEOLOUS PNEUMONIA. 127 

creeping, insidious form of inflammation, which too 
often throws the practitioner off his guard. No positive 
complaint is made. The child droops, and appears 
weak and exhausted. Imagining that the disorder has 
weakened his patient, the practitioner directs some mild 
tonic. Meanwhile, pneumonic engorgement (or pneu- 
monia in its first stage) creeps on. The lungs become 
more and more congested, and at length solidified. A 
convulsive fit now takes place. Alarm is taken, and 
leeches are applied, but the mischief is irreparable, 
Dyspnoea increases. The child becomes drowsy, the 
feet cold. The pulse sinks. Fluid effusion now takes 
place from the bronchial membrane. Another and 
another fit succeeds. Rattles are heard in the throat 
The child dies ! 

[Pneumonia forms, as our author remarks, one of the most frequent, 
as well as the most dangerous complications of measles, and demands 
that the disease should be narrowly watched, both during its progress 
and its decline. Its course is sometimes more marked than stated here. 
"When occurring during its progress, there is persistence and increase of 
cough, continuance and perhaps exacerbation of fever, either without 
any abatement, or after it has been less for one or two days, increased 
dyspnoea, with more or less lividity of the countenance, while the 
stethoscopic signs, at least in children of five years and upwards, will 
often clearly indicate the change which is taking place in the lungs. 
Sometimes the patient will have been unattended until dulness, or 
percussion and bronchial respiration, show that it has reached the second 
stage.] 

Such is the usual course of rubeolous pneumonia. 
Sometimes the inflammation is of a different kind, 
which runs on to the rapid development of tubercles, 
and the formation of small abscesses. The child ema- 
ciates, becomes consumptive, and dies. This series of 
changes may occupy a month or six weeks. The for- 



128 SEQUELAE OF MEASLES. 

mer is an affair of eight or ten days from the decline of 
measly eruption. I am sore I speak much within 
bounds, when I say (hat nine tenths of the deaths by 
measles occur in consequence of the subacute form of 
pneumonia now described. I do not remember to have 
ever seen a case of measly pleuritis. 

[The development of tubercles after measles, referred to by our 
author, occurs in other parts of the system as well as in the lungs. 
Children of only one, two, or even three years of age, more rarely 
emaciate from tubercles in the lungs alone than is generally supposed, 
and the cases in which great emaciation takes place are probably those 
in which tubercles affect the abdominal as well as the thoracic organs. 

Perhaps the abdominal affection, in which our author speaks of the 
supervention of marasmus in a subsequent paragraph, may depend upon 
tuberculosis of the mesenteric glands.] 

The ophthalmia succeeding measles is of the kind 
usually called scrofulous. The irritability of the retina 
is often so intense that it is impossible, even by force, 
to open the eyelids. There is redness of the conjunc- 
tiva, but not proportioned to the intolerance of light. 
This state of the eye may continue for w r eeks, nay, 
even for months. Eczematous runnings behind the ear 
are frequent after measles. So is otitis, or earache. 
The glands of the neck harden or advance to indolent 
abscess. 

I have not yet spoken to you concerning the state of 
the bowels in measles, because in many cases the abdo- 
minal viscera remain throughout unaffected. But, at 
times, especially during secondary fever, a subacute 
form of mucous enteritis is set up. The child cries 
exceedingly (which it does not do in the thoracic com- 
plication), and draws the legs up to the belly. There 
is diarrhoea, the stools being of unhealthy aspect, green 



MALIGNANT MEASLES. 129 

and very offensive (from the foul and depraved state of 
the secretions), and often ejected with force. Ulcers 
occupy the angles of the mouth. The tongue is red at 
first, and afterwards aphthous. The countenance 
expresses great febrile anxiety. Marasmus supervenes 
— that is, the child emaciates, and in this state of 
things, death may ensue. 

[Our author has not mentioned a diarrhoea frequently occurring 
during the decline of measles, and which requires no interference, unless 
when it tends to excess, in which case it may be restrained by mild 
anodynes and attention to diet. 

Diarrhoea also sometimes precedes, and at other times accompanies 
the eruption, doubtless a mere effect of the hyperaemia of the mucous 
membrane of the intestinal canal, as a part of the disease, and having 
no influence over the progress of the eruption. These must be distin- 
guished from the enteritis described by our author in the preceding 
paragraph.] 

In India, and other hot countries, thoracic complica- 
tions are rare. Diarrhoea and dysentery prove the 
usual and often troublesome sequelae. The mesenteric 
glands are not often affected. Sydenham has the merit 
of having first detected both the real nature and the 
appropriate treatment of this complication. 

[Death sometimes takes place in measles from obstruction of the 
deep jugular vein, caused by pressure from enlargement of lymphatic 
glands. For a case of this kind in a stout healthy infant, twelve months 
old, which occurred in the practice of Dr. J. T. Metcalfe, of this city, 
reported to the New York Pathol og. Soc, see New York Jour. Med^ 
Ac., July, 1S50, p. 37.] 

Measles does not always display the steady though 
perhaps severe course I have now described. There is 
a malignant or putrid variety of measles, sometimes 
occurring isolated in the course of epidemics of average 

9 



130 MALIGNANT MEASLES. 

intensity, sometimes giving a decided character to the 
epidemic. In 1745, measles of this kind appeared in 
Plymouth, and found an able historian in Dr. Huxham. 
In 1763, occurred the celebrated epidemic of malignant 
measles described by Sir William Watson with such 
accuracy, that the disease was long known as Watson's 
measles. In 1816, a similar epidemic prevailed in 
Edinburgh. In 1839, it was observed at Hertford 
among the children of Christ's Church Hospital, who 
are there educated. The characteristic features of 
malignant measles are — J. Severity of the initiatory 
fever. 2. Irregularity in the course of the symptoms, 
especially in the appearance and aspect of the eruption. 
3. Severe implication of the brain. 4. Implication of 
the abdominal viscera. 5. Concomitant disorganization 
of the blood, leading to petechias and haemorrhages. 

The eruptive fever is severe, and attended with 
unusual symptoms. The fever is typhoid, not inflam- 
matory. The eruption appears too early or too late. 
It perhaps recedes after having shown itself, and par- 
tially reappears. The stomach is irritable ; vomiting is 
both severe and protracted ; there is delirium, with 
wildness of eye, or coma; the belly is tender; there is 
purging of unhealthy stools ; the extremities are cold, 
the pulse small and wavering : on the surface appear 
petechias or ecchymosed patches of eruption ; the fauces 
assume a livid, or dusky red color; blood passes by 
stool ; there is much oppression at the prsecordia, and 
abundant muco-serous discharge from the chest, indi- 
cating the congested condition of the lungs and their 
mucous membrane. In these almost hopeless circum- 
stances, children may die in forty-eight or sixty hours, 
asphyxiated by the condition of the air-passages ; others 



APPEARANCES ON DISSECTION. 131 

die of coma or convulsion ; some are worn out more 
slowly by diarrhoea and bloody stools. 

The appearances presented on dissection of those 
who die either of the malignant measles or of the tho- 
racic complication already described, present features 
which might readily be anticipated from the character 
of the symptoms. The bronchial membrane is spongy ; 
abundant serous effusion escapes from the lungs on 
pressure ; portions of their substance are consolidated ; 
the larynx is eedematous. Abscess and purulent infil- 
tration are rare. In the abdomen appear patches of 
ulceration, with or without enlarged mesenteric glands. 
In the ventricles of the brain, you will occasionally find 
effusion of serum. 

I have, lastly, to speak to you of that, truly frightful 
combination, measles with the tendency to gangrene. 
This is sometimes witnessed in children of the upper 
ranks who are of extremely weak habit, but all the 
worst cases appear in the half-fed children of the lower 
ranks, inhabiting damp cellars, and inhaling an impure 
air. The measles, having superadded to it such sources 
of constitutional debility, proves too much for the sys- 
tem. The first evidence of the gangrenous disposition 
will probably be a sloughy state of leech-bites or blis- 
tered surfaces, if leeches or blisters had been applied, 
with small ragged ulcers on the inside of the cheek, 
exhaling an offensive odor ; soon after which the true 
cancrum oris begins to show itself. A hard round 
spot, like a marble, occupies the inside of the cheek, or 
a small black point appears at the corner of the mouth. 
A tooth drops out. In twenty-four hours, gangrene has 
spread so as to occupy a large portion of the inner and 
some part of the outer cheek ; at length the whole 



132 PROGNOSIS IN MEASLES. 

cheek is eaten away, and the nose and eye are invaded. 
Happily, however, death puts a period, though not 
always an early period, to this distressing scene. 

Cases of recovery from cancrum oris are seldom seen, 
except in adults. The affection is not peculiar to the 
latter stages of measles. I have seen it following small 
pox, and occurring in the progress of infantile remitting 
fever ; hut there is something in the rubeolous miasm 
peculiarly depressing to the vital power, and hence can- 
crum oris is much more common after measles than 
after any other exanthematic malady. Mercurial pre- 
parations have often, but unjustly, been accused of occa- 
sioning or at least favoring the disposition to cancrum 
oris. It often, however, appears where no such drug 
had been administered, and is, in truth, entirely depend- 
ent on constitutional debility. 

The prognosis in measles is easily laid down. The 
cause of death in the great proportion of cases is pneu- 
monia. All symptoms indicating pulmonic congestion, 
and its consequences, whether affecting the chest, head, 
or belly, such as coma, convulsions, or vomiting, are pe- 
culiarly to be dreaded. It has generally been remarked 
that measles does not fall with such severity on pregnant 
and parturient women as the other exanthemata. In- 
deed, the mortality by measles among adults is very 
low. In hot countries measles is not viewed with alarm, 
evidently from the absence of thoracic complication. 

The following are the observations of authors regard- 
ing the proportion of deaths to recoveries : — In one of 
Sir W. Watson's epidemics, the deaths were as high as 
ten per cent. Dr. Home estimated the proportion at 
eight per cent. Mr. De la Garde states that, at Exeter, 
in 1824, he lost eight per cent. Dr. Percival, of Man- 



STATISTICS OF MEASLES. 



133 



Chester, lost ninety-one out of 3807, which is one in 
forty, or two and a half per cent. Dr. Adams states, as 
the generally received opinion in his time, that commu- 
nibus annis, measles does not prove fatal to more than 
three per cent. I have given (page 6) a table of the 
deaths by measles during three years. It will be seen 
that in 1839, there died, throughout England and 
Wales, by measles, 10,937 persons: this, at three per 
cent., would make the total attacked, 364,566, about 
the number of those born who attain the age of three 
years. 

Mr. Fair's Fourth Report gives tables of the deaths, 
by measles, throughout England and Wales, for three 
years and a half, on a very extended scale. The fol- 
lowing abstract presents an interesting picture of the 
prevalence of the disease in this country, and of its 
varying intensity : — 

Table exhibiting the Deaths by Measles throughout England and Wales, 
within Fourteen Quarterly Periods, extending from 1st July, 1837, 
to Z\st December, 1840. 



QUARTERLY PERIODS. 


1837. 


1838. 


1839. 


1840. 


Jan., Feb., March . . . 
April, May, June . . . . 
July, August, Sept. . . . 
Oct., Nov., Dec 

Total Deaths . . . 


2362 
2392 


2022 
1512 
1037 
1943 


2074 
3204 
2767 
2892 


2836 
2641 
1739 
2110 


4754 


6514 


10,937 


9326 



We learn from this table that the average annual 
deaths by measles in England is about 8500, which is 
nearly one-fortieth part of the total mortality. Season 
would appear to have less influence on the mortality of 
measles than might have been anticipated. 

[From a table exhibiting the months during which death took place 



134 DIAGNOSIS OF MEASLES. 

in measles, within quarterly periods, in the city of New York, from Jan. 
1, 1830, to Dec. 31, 1844, inclusive, embracing a period of fifteen years, 
and 2104 deaths, we find that the mortality was greatest during the 
months of January, February, and March, and least during the months 
of October, November, and December, the numbers being respectively, 
during these two quarterly periods, 610 and 384; the numbers during 
the quarterly periods of April, May, and June, and of July, August, and 
September, being respectively 5*74 and 536.] 

The diagnosis of measles need not detain us. From 
scarlatina it is to be distinguished — 1. By the character 
and duration of the eruptive fever ; 2. by the character 
and general aspect of the eruption ; 3. by the state of 
the throat. In a subsequent lecture, these points will 
be stated more in detail. From lichen febrilis, measles 
is distinguished by attention to the initiatory stage. 
This stage is four days in measles ; in lichen, twenty- 
four hours. 

[Chomel adds to the above diagnostic marks of measles mentioned by 
authors, 

1. Spots like those of ecchymosis under the skin, which he says are 
not rare, and are peculiar to measles, and seen in some of its anomalous 
forms. 

2. Sputa of a peculiar character, which he describes as consisting of 
opake, nummular masses, of a greyish color, floating in an abundance 
of liquid, and resembling the sputa of the second stage of phthisis. But 
in phthisis, the fluid in which they float is clear and transparent, while 
in measles it is dull, cloudy, and lactescent. 

M. Chomel considers this an important diagnostic mark, affording aid 
in epidemics when the eruption does not make its appearance, and also 
when the eruption is suddenly suppressed. This mark can only be of 
service in adults, as infants do not eject the sputa.] 

The real difficulties of diagnosis arise out of the con- 
currence of two exanthemata. Measles has been known 
to co- exist with small pox. Mr. De la Garde has re- 
corded an interesting case of this kind which occurred 



DIFFICULTIES OF DIAGNOSIS. 135 

at Exeter in the epidemic of 1824. Dr. Russell has 
detailed like cases occurring at Aleppo. Many years 
ago I attended, with the late Mr. Corbett, a case which 
exhibited the combined character of measles and scarla- 
tina. There was an eruption of measles, with the 
sloughy throat of scarlatina. I have put on record the 
particulars of a family invaded at the same time by 
the miasms of scarlatina and measles ; one child took 
measles first, and scarlatina afterwards ; the other took 
scarlatina first, and measles afterwards. The character 
of the eruptive fever in each of the four seizures, indi- 
cated the nature of the disease which was to follow. 

Dr. Russell, discoursing on the reciprocal influence 
of small pox and measles, informs us that he carefully 
watched above 300 cases in which these diseases suc- 
ceeded each other, at a time when they were both epi- 
demic at Aleppo (1765). He noticed that the measles 
rarely succeeded small pox in less than 20 days from 
the first appearance of the eruption. Several cases, 
however, were observed where small pox succeeded 
measles before the total disappearance of rubeolous rash 
from the extremities — that is, on the 11th or 12th day 
of the eruption. He adds, " so little did the quality of 
the first disease influence that of the second, that a 
mild distinct small pox was often observed to follow the 
worst kind of measles, and vice ve?sd" 

Willan relates the case of a young man, aged eighteen 
inoculated for measles and cow pox on the same day ; 
the cow pox took the lead, measles following at the end 
of sixteen days. I described (page 119) a case very 
analogous ; but there measles had the start, and after 
sixteen days, cow pox had its turn. It is singular that 



136 PATHOLOGY OF MEASLES. 

in each case sixteen days should he the period of sus- 
pension. This, I am persuaded, was not accident. 

The pathology of measles (by which I understand 
all speculations regarding the causes of the disease) af- 
fords much curious matter for inquiry. That measles 
is the product of a specific miasm, and is never gene- 
rated de novo, is now the universally admitted doctrine. 
Historical facts countenance this opinion. Measles 
never gained footing at St. Helena until 1808. For 
twenty-five years it was absent from the island of Ma- 
deira ; and when, in 1808, it did invade the island, it 
found almost the whole population susceptible ; in four 
months it destroyed 700 lives. Australia and Van 
Diemen's land are to this day exempt from measles. 
They have, indeed, what is called Van-Diemeri s-Land 
?neasles, which is a species of febrile lichen, affording no 
protection against the measles of this country. 

[An analogous fact to the one stated respecting Madeira, is recorded 
as having occurred at Thorshaven, the capital of the Faro Islands. A 
writer in the London Med. Gaz. (July 10, 1846, p. 83) says, "letters 
lately received from Thorshaven contain the intelligence that the mea- 
sles, which had not appeared in that island since 1781, and which, in 
that climate, always assumes the character of a terrible epidemic, had 
broken out there. Of the 800 inhabitants of that town, more than 700 
had been attacked by it, and from 10 to 15 persons daily fell victims to 
it. The only persons spared were the native old men who had the dis- 
ease in 1781, and the foreigners who had been attacked by it in foreign 
parts." 

These facts, interesting as they are, cannot be quoted in favor of either 
eide of the question as to the origin of measles, being deficient in proof 
as to the importation of the disease. We have already stated (page 80) 
reasons for believing in the possibility at least of the occurrence of this 
exanthem independently of contagion. Dr. M. F. Cogswell, in a letter 
to Dr. E. H. Smith, June, 179S, records two such cases {Med. Bejjos., 
1799, vol. ii. p. 281), and we have also given the authority of Dr. 



RECURRENCE OF MEASLES. 137 

Webster and Prof. J. M. Smith on the same side. To these, we may 
add the name of Dr. Good in favor of the probability of such an origin.] 

The statistical details already given show how uni- 
versal is the susceptibility of this contagion. The re- 
currence of measles has been recorded, but the well 
authenticated cases are few. Dr. Baillie has put on 
record seven, of whom five were brothers and sisters. 
Four had recurring measles at the interval of six 
months ; one at the interval of twenty-one years. Dr. 
Webster has published three similar cases, where the 
intervals were respectively two years, four years, and 
six years. Two cases are recorded by Dr. Home. 

In all speculations on the recurrence of measles, it 
should be remembered that one form of lichenous erup- 
tion closely resembles measles in its outward aspect, 
and, consequently, that the periods of incubation, access, 
and decline, are of more value in diagnosis than the 
character of the eruption. 

[Details of the cases reported by Dr. John Webster, referred to by 
our author, may be found in the Medico- Chirurg. Trans., vol. xxii. p. 
245. 

Dr. Joseph Moore also gives a case of a female infant, 22 months old, 
attacked with measles in the latter part of May, and again on the 31st 
July, both .passing through their regular stages [Medico- Chirurg. Trans., 
vol. xxi., 1838). 

Rayer states that he met with three very remarkable instances of the 
recurrence of measles during the interval between the first and second 
editions of his work on Diseases of the Skin, and quotes several authors 
who have met with such a recurrence {Mai. de la peau, t. i. p. 180). 

Bateman admitted the possibility of such a recurrence, although Rc- 
senstein met with but a single instance of it in a practice of forty years. 

Dr. Van Diezen relates an instance of three successive attacks in a 
child three years old, at Antwerp. The first attack was in February, 
the second the following March (commencing the 4th), and the third 



138 INOCULATION OF MEASLES. 

on the 12tli of April. Desquamation took place each time. (Bullet. 
Gintr. de TMr., Sept. 15, 1848, p. 239.)] 

The inoculation of measles was first thought of by 
Dr. Home, of Edinburgh, in 1758. He inoculated with 
the blood, applying cotton dipped in the blood of a 
measly patient to a wound in the arm. We read, that 
febrile symptoms appeared on the sixth day, of a mild 
character, and that no secondary complications ensued. 
Early in this century, Mr. Wachsel, of the Small Pox 
Hospital, inoculated a lad, Richard Brookes, with fluid 
taken from some of the measly (or miliary) vesicles, and 
the inoculation was successful. In 1822, Professor 
Speranza, of Mantua, inoculated himself and six boys, 
in the manner recommended by Home, with complete 
success. In other trials, it does not appear that the 
resulting disorder was at all mitigated. 

The latest recorded experiments are those made in 
1842, in Hungary, by Dr. Katona. We are informed 
that he failed in 78 cases only out of 1112 (seven per 
cent.), and that the resulting disorder was mild, contrast- 
ing favorably with the severity of the reigning epidemic. 
No deaths occurred among the inoculated. The in- 
fecting blood was drawn from the surface most efflo- 
resced ; we further learn, that a red spot with surround- 
ing areola followed- On the seventh day, rigors 
occurred, with the usual catarrhal symptoms. On the 
ninth or tenth day, eruption manifested itself, which 
declined on the 14th. On the 17th day from inocula- 
tion (7th or sometimes 8th from eruption), the patient 
was convalescent. 

These experiments certainly merit more attention 
than they have yet received in this country. I have 



STATISTICS OF MEASLES. 139 

lately been inclined to think, that the child, whose case 
I detailed (page 119) as having undergone cow pox 
after measles, received the germ of measles and of cow 
pox at the same time ; in other words, that, unknown to 
me, the child that furnished the lymph was incubating 
the measles, with the zuma or poison of which the vac- 
cine matter had become impregnated. When the case 
occurred, I presumed that the germ of measles had been 
received by accidental infection. 

[The communication of small pox to the foetus in utero is a well 
established fact — such communication in the case of measles is not well 
known. In this point of view, the following is not without interest, 
taken from Dr. West's Report on Progress of Midwifery, &c, in Brit, 
and For. Med. Rev., Oct. 1845, p. 549. 

"Dr. Hedrick relates the history of a woman, who, having been at- 
tacked by measles at the end of her pregnancy, gave birth, on the fourth 
day of the disease, to a female child, who was covered with the eruption 
of measles, and was suffering from catarrh, cough, sneezing, inflamed 
eyes, &c, but recovered in a few days."] 

This brings me to the infective nature and epidemic 
diffusion of measles, which must detain us for a short 
time. 

It has been rendered highly probable, more especially 
by a case recorded by Dr. Williams of this Hospital, 
that the blood throws off infective emanations during 
the eruptive fever, and prior to any eruption. The in- 
fective distance is unknown. It was formerly held, 
that measles sets in in January, reaches its crisis at the 
vernal equinox, and ceases in the summer solstice. 
Modern statistics overthrow all these long-established 
notions. The quarterly deaths by measles in London, 
in 1841, were 158— 147— 260— 408,— total, 973. In 
1842, they approximated still closer, being 308 — 334 — 



140 STATISTICS OF MEASLES. 

311— 340,— total, 1293. No such law of epidemic 
culmination and decline is here apparent. In fact, the 
recurrence and duration of epidemics is, in Europe, 
wholly irrespective of season. In Bengal, however, the 
prevalence of measles (or Hacem) is governed by dif- 
ferent laws. There the disorder never originates except 
in the cold season. It begins about the middle of that 
division of the Indian year, and continues till the hot 
season is established. Season affects too, there, the 
character of the symptoms. In the hot months the 
eruption is more vivid and more elevated, and the 
internal organs comparatively but little affected. In 
the cold season, the affection of the mucous tissues is 
best developed. 

Measles is undoubtedly increasing in severity, if not 
in quantity, in this country. In 1748 only ten deaths, 
and in 1754 only twelve, are recorded in the bills of 
mortality as having arisen from measles ; whereas the 
weekly average of the last four years is thirty, and the 
annual average, 1560. 



[Measles in the adult differs but little in its character as exhibited in 
infants and children. M. Levy, who has written an interesting paper on 
the disease in that class, thinks that the mortality is less in proportion 
among adults than among children. He explains this by a greater 
resistance of the organism of the adult ; a less liability to lobular pneu- 
monia ; a greater facility of clinical examination, and greater certainty 
in treatment. He says that men from 18 to 30 years of age do not 
bear bleeding better than children, as it might be supposed they would. 
The inflammation, as he remarks, is not of a simple and legitimate 
character, but approaches congestion in its nature ; and is frequently 
accompanied by nervous erethism or prostration of strength. This 
remark is true of different epidemics. 

For an analysis of the paper of M. Levy, see Medico- Chirurg. Bev., 
Oct. 1847, p. 477. 



STATISTICS OF MEASLES. 



141 



Death by measles would seem to be very rare in proportion in chil- 
dren during the earlier months. 

Dr. Otto never saw a child under four months of age have measles. 
The greatest number of deaths occurs between the ages of two and five 
years, as is seen by the following tables : 

Ages of 978 persons who died of measles in New York during the 
eight years from 1837 to 1844 inclusive, and of 414 who died in Phila- 
delphia of the same disease, during nine years from 1837 to 1845 
inclusive : — 





New York. 


Philadelphia 


One year and under, 


178 


. 77 


Between 1 and 2 years, . 


298 


. 121 


" 2 and 5 " . 


402 


. 165 


" 5 and 10 " . 


. 74 


. 41 


" 10 and 20 " . 


11 


3 


" 20 and 30 " 


. 10 


5 


" 30 and 40 " . 


2 


1 


" 40 and 50 " . 


2 


1 


Unknown, 


1 

. 978 





Total, . 


. 414 



The annexed table, by Dr. Watt, of Glasgow, similar in its nature to 
the one respecting the mortality of small pox in the same cities, on page 
72, shows the percentage of deaths by this disease at different ages to 
the whole number of deaths by that disease, in the cities of Glasgow, 
Edinburgh, New York, and Philadelphia : — 





Glasgow. 


Edinburgh. 


New York. 


Philadelph 


Under 2 years, 


. 52.76 


60.25 


47.48 


45.76 


u 5 * « 


. 88.08 


92.30 


90.09 


89.83 


" 20 « 


. 99.35 


99.67 


98.27 


99.43 


Above 20 years, 


0.64 


. 0.42 


1.72 


0.56 



As Dr. W. remarks, "the total amount of deaths in each of these 
towns was very different, and yet it will be observed that the proportion 
of deaths, at different ages, to the whole deaths by measles, is very 
nearly the same in each of these towns, the variation being chiefly at 
ages under two years." (Proceedings of P kilos. Soc. of Glasgow, June 
3, 1844 — taken from Amer. Jour. Med. Sci., April, 1845, p. 515.) 

Measles would appear to be much less fatal among blacks than among 
whites in this city. During the eight years in New York, extending 



142 TREATMENT IN THE EARLY STAGE. 

from 183*7 to 1844 inclusive, the per centage of deaths to the population 
of each was among the whites in the proportion of about one to 200, 
and among blacks in that of about one in 1000. 

In Charleston (S.C.), on the contrary, as will be seen by the statistics 
on page 35, the mortality by measles was twice as great among blacks 
as among whites, during the series of years there mentioned.] 

If I have rightly laid down the pathology of measles, 
the principles of treatment will flow naturally from it, 
and in truth there never has been any serious difference 
of opinion on this subject of late years. In regular 
measles, an antiphlogistic method of treatment has been 
advised. The only doubt that can be raised is as to 
the extent to which such measures should be carried, 
and the period to which they should be protracted. 

Moderate warmth is desirable during the initiatory 
fever, to encourage eruption, and thus relieve mucous 
congestion. This may, however, be carried too far. 
On the 15th June, 1830, I attended R. W. (aetatis 5), 
who was kept so hot by blankets, flannel vests, a large 
fire, and the closure of all doors and windows, that the 
child was nearly comatose. Perspiration was flowing 
from his skin. There was dyspnoea and epistaxis. The 
blood was gorging the head and chest. The loss of 
some blood from the arm, a total change of regimen, 
and lotions of vinegar and water, soon set matters to 
rights, and the measles ran its regular course. 

On the appearance of eruption, your object is simply 
to avoid occasions of aggravation. Let the patient be 
confined to bed, take occasionally some castor oil, and 
a simple saline draught, with syrup of tolu and some an- 
timonial wine, every four hours. A saline powder, 
such as three grains of potassse sulphas, with five of 
sugar, may be given to children of very tender years, or 



MALIGNANT MEASLES. 143 

the mistura amygdalae with nitre. To allay the cough, 
a little syrup of poppies may he taken, especially at 
night. 

If, after the completion of eruption, cough should 
remain, try what a mustard poultice, or the acetum 
cantharidis, or a blistering plaster, will do. If the cough 
still continues, mischief is brewing, which neglected, 
will lead to more serious consequences. Therefore 
apply one, two, or more leeches, according to the age 
of the child ; and if the symptoms indicate confirmed 
pneumonia, take away some blood, from the arm if you 
can, — if not, from the jugular vein. Do not attempt to 
combat measly pneumonia by purgatives, nor by calo- 
mel and opium. Tartar emetic, pushed in the first 
instance to full vomiting, and then given in more mode- 
rate doses, is sometimes sufficient, but it cannot generally 
be relied upon. 

[It is important to bear in mind that dyspnoea, severe cough, and a 
deep color of the face, do not always with certainty indicate inflammatory 
affection of either the bronchial tubes or of the lungs themselves. The 
symptoms may all be produced by a congested state of the mucous 
membrane of the respiratory passages, as a part of the disease, analogous 
to that state of hypersemia upon which the eruption on the skin depends, 
and may rapidly disappear as the eruption becomes developed over the 
surface. The continuance of these symptoms after the eruption is well 
out, is indicative of more serious trouble, as our author remarks.] 

In the malignant measles, with cold extremities, 
diarrhoea, and receding eruption, no plan of treatment 
is very successful. Diarrhoea must be restrained by 
one, two, or three grains of Dover's powder, given along 
with half a grain of calomel, every four hours. The 
child should be put into a warm bath, and mustard 
poultices applied to the feet and epigastrium. Blisters 



144 TREATMENT OF THE SEQUELAE. 

are dangerous in this state, from their tendency to de- 
generate into sloughing sores. 

The sequelae of measles must be treated on the same 
general principles. If secondary fever runs high, mild 
aperients (such as potassae sulphas cum rheo, or infus. 
rosaa cum magnes. sulph.) are indispensable. Where 
pneumonia threatens, blood should be drawn, and the 
other means of derivation adopted to which I have just 
adverted. 

In the abdominal complication, your sheet anchor is 
calomel and Dover's powder. Sydenham drew blood in 
these cases too, and, I dare say, by so doing saved many 
a child's life. The diet throughout must be perfectly 
simple and unirritating. Gruel, tea, arrow-root, rice- 
milk, roasted apples, are to be the staple articles. 

In the treatment of cancrum oris, I can give you but 
little help, and less hope. Wine and bark must be 
administered freely. The chlorate of potash, in the 
dose of five grains every three hours, has lately been 
tried, with some alleged appearance of benefit. Diar- 
rhoea must be restrained by aromatic confection with 
laudanum. You may dress the gangrenous surface 
with Peruvian balsam. You will, as far as may be, 
support the child's strength by beef tea, eggs, and blanc- 
mange. 

[It should be borne in mind that measles, as well as the other exan- 
themata, is a self -limited disease, and that it seldom of itself proves 
fetal ; such a result, when it occurs, being almost always owing to some 
complication, of which the most frequent is bronchitis or pneumonia. 
Hence, in most cases of simple measles, as it occurs with us, but little, 
and sometimes no medication is called for. The syrup of ipecac in flax- 
seed tea is a convenient and effectual mode of keeping up a gentle dia- 
phoresis, and of allaying the irritation of the mucous membranes. When 
congestion of the lungs is threatened, the application of a large warm 



TREATMENT OF MEASLES. 145 

flaxseed or bread and milk poultice, will often afford great relief. A 
sinapism may be applied between this and the chest, and kept on until 
irritation is produced, and then withdrawn, and the emollient poultice 
continued. A little of the tincture of hyoscyamus or paregoric is often 
isary to allay the irritating cough. 

I have used the above plan of emollient poultices, alternated with 
sinapisms, for several years in children suffering under congestion of the 
lungs, and also in inflammation of them, and with much satisfaction, 
having rarely resorted to leeches. 

The tendency to diarrhoea in many cases renders it rather advisable 
to avoid tartar emetic, unless in those of vigorous habits, and where the 
inflammatory action is high, especially in infants and delicate children. 

"When the eruption is tardy in its development, or shows a tendency 
to recede, with symptoms of want of action, the means indicated are 
twofold : — such as act on the surface itself, and such as act on the gene- 
ral circulation. 

Under the first head belong the warm bath, rubefacients, blisters, &c. 

The use of internal stimulants requires more caution, from the clanger 
of producing congestion of internal organs, but still must sometimes be 
resorted to ; and in such cases, wine whey, either with or without car- 
bonate of ammonia, may be used with advantage. 

Both external and internal means can be used together with benefit. 

In the cachectic condition which sometimes succeeds measles, and 
especially in those of strumous diathesis, and with a predisposition to 
tuberculosis, tonics will be found useful, more particularly preparations 
of iron, as the citrate or iodide, with which probably cod-liver oil can 
often be associated with great benefit.] 



10 



LECTURE VII. 

HISTORY AND PHENOMENA OF SCARLET FEVER. 

First notices of scarlatina. Epidemics of the 17th and 18th centuries. Ef- 
fects of the miasm. Division of scarlatina into species. Incubative stage. 
Phenomena of scarlatina mitis. Phenomena of the scarlatina anginosa. 
Character of the accompanying fever. Character of the eruption. Con- 

f comitant affection of the throat. Implication of the eye and larynx, 
Cerebral complication. Affection of the heart. Phenomena of the angina 
maligna putrida. Scarlatina with collapse. Sequelae of scarlet fever. 
Sloughing of the cellular membrane of the neck. Desquamation ; debi- 
lity ; mucous enteritis ; dropsy. Phenomena of scarlatinal dropsy, and 
consecutive convulsion. 

The extent and seventy of scarlet fever at the present 
time are such as to demand from you the most patient 
attention and diligent study. It is obviously an in- 
creasing malady, and seems likely, in after times, to 
occupy that painful pre-eminence among the fatal dis- 
eases of early life which small pox formerly enjoyed. 

By whom the term scarlatina was first used is not 
well known ; perhaps by Sydenham, for I cannot find 
any traces of the word before his time. The mild vari- 
ety of the disease described by him existed in the East 
at a very early date, but you would in vain search for it 
in the writings of the ancient Greeks and Romans. It 
probably invaded the world soon after small pox and 
measles had made their deb lit, for the Arabian physi- 
cians describe a species of measles, which, from the 
extent of desquamation, we may be assured was scarla- 
tina. In the ages which succeeded, scarlatina continued 
to be confounded with rubeola. 



FIRST NOTICES OF SCARLATINA. 147 

In the year 1610 an epidemic angina, with scarlet 
eruption, raged in Spain, from which country it passed 
over, in 1618, to Naples, then governed by a Spanish 
viceroy. We naturally look therefore to Spanish and 
Italian authors for the first description of the anginose 
or malignant scarlet fever. The early Spanish writers 
are Ludovicus Mercatus (1612) and Michael Heredia 
(1626). The latter is peculiarly full and clear in his 
descriptions. The Italian authors are Sgambatus " de 
pestilente faucium affectu Neapoli scevienle" (1620) ; 
and CEtius Clems " de morbo strangulator™" (1636). 
Sennertus noticed the same disease in Germany about 
1625. Diemerbroeck of Utrecht, in 1640, described 
under the title of purpura, a disease which he believed 
to be a variety of measles, but which was obviously 
scarlatina. The milder type of the same disorder was 
seen by Sydenham in London between the years 1670 
and 1675. He describes it as a disease more in name 
than in essence, and fatal only through the officiousness 
of the physician. He was ignorant of any connexion 
existing between it and the angina putrida maligna of 
the Continental authors of that day. 

Scarlet fever, in its mild form, first reached Edin- 
burgh in the year 1680. Sir Robert Sibbald, physician 
to King Charles II., for Scotland, says, "It is so recently 
introduced, and so little understood, that I cannot ven- 
ture to offer any observations either on its theory or 
treatment." Morton described scarlatina as it appeared 
in London in 1689 and the three following years. It 
was a severer epidemic than that witnessed by Syden- 
ham, but Morton was so fully convinced of its intimate 
relation to measles, that his details cannot be trusted. 

In 1747-8, London experienced a severe scarlatinal 



148 SCARLATINAL EPIDEMICS. 

epidemic. The historian of it was Dr. Fothergill, then 
a young man entering on his professional career. His 
work was entitled " An Account of the Sore Throat 
attended with Ulcers, a disease which hath of late years 
appeared in this city, and in several parts of the 
nation." It was prefaced by a very lucid explanation 
of the opinions of the Continental writers of the pre- 
ceding century. He distinctly traces the disease to 
" the reception into the habit of a putrid virus or miasm 
sui generis by contagion, and principally by means of 
the breath," but he professes his inability to explain the 
cause of its peculiarly malignant or putrid tendency. 
The success of this work was so great as rapidly to 
place its author at the head of his profession in London. 
In compliment to him, the complaint was long called 
Fothergill's sore throat. 

The same epidemic spread to Plymouth, where it 
raged from 1751 to 1753, and was most ably described 
by Dr. Huxham. In 1778, an epidemic scarlatina 
devastated Birmingham, of which Dr. Withering has 
published an account. In the first edition of his work 
(17 79), Dr. Withering drew a formal diagnosis between 
the scarlatina anginosa of the old authors and the 
angina maligna or ulcerous throat of Fothergill. In 
1793, a second edition of this work appeared, wherein 
Dr. Withering abandoned his early prepossessions, and 
with great but unusual candor proclaimed his belief in 
the identity of the two diseases — a doctrine which has 
never been questioned since that period. Sauvages, in 
1767, and Cullen, in 1792, had separated them in their 
nosologies. As this opinion of Dr. Withering, there- 
fore, forms an epoch in the history of scarlatina, I shall 
give you his precise words (dated 1793). " From the 



EFFECTS OF THE MIASM. 149 

most assiduous attention to this disease during a period 
of fifteen years, — from observing it in every difference 
of season, exposure, age, and temperament, I am now 
persuaded that the scarlatina anginosa and the angina 
gangrenosa constitute but one species of disease — that 
they owe their existence to the same specific contagion 
— that the varieties in their appearance depend upon 
contingent circumstances, and that their greatest differ- 
ences are not greater than those of distinct and conflu- 
ent small pox.'' 

Scarlet fever prevailed in Dublin from 1834 to 1842. 
An accotmt of this epidemic has recently been published 
by Dr. Kennedy. His work forms the latest, but at the 
same time one of the most valuable monographs which 
we have of this disease. It is peculiarly rich in the 
details of post-mortem appearances.* 

Scarlatina, taken in its widest sense, is a fever some- 
times inflammatory, sometimes typhoid, the offspring of 
a morbid poison gaining access to the body by the 
mode of infection only, characterized by a short period 
of incubation, an eruption rapidly developed, and an 
inflammation of the fauces, having a strong tendency to 
terminate by sloughing. In its mild form, the disease 
does not last more than a week ; but when assuming 
its aggravated type, it may be protracted to a month, or 
terminate fatally in a few hours. Such a disease does 
not, like measles, invade a large proportion of mankind 
during infancy, but having been undergone, the suscep- 
tibility to future attacks is exhausted. 

The points that will demand attention from you are, 

* For abstract of this work, see Brit, and For. Med. Rev., April, 1844. 



150 DIVISION INTO SPECIES. 

1. The phases, modifications, or types of the disease ; 

2. the mode of its propagation ; 3. the amount of mor- 
tality which it occasions ; and 4. the treatment adapted 
to its varied aspects. 

I have explained to you that the fever now to be 
treated of does not originate (under common circum- 
stances) from any spontaneous movements in the blood 
or humors of the body. A zuma, ferment, or poison, 
must have access to the body, before the blood is set in 
motion, so as to develope the phenomenon now called 
scarlet fever. The effects produced by that poison may 
be exerted on the skin alone, and then the accompany- 
ing fever is slight ; or it may develope a more serious 
kind of ardent fever, and then the skin and throat will 
both exhibit appearances. It may so seriously affect 
the whole system as to produce intense fever, in which 
case the throat receives nearly the ivhole shock, the 
skin being only partially affected. Nay, in some 
extreme cases, the nervous system shall be so com- 
pletely depressed and subdued by the virulence of the 
miasm, and the mass of blood so thoroughly poisoned 
and disorganized by it, that all the ordinary appear- 
ances of scarlatina are masked. Petechias, coma, and a 
sloughy state of the throat, alone appear. Life rapidly 
yields under such an attack. 

From this rude sketch of the effects of the scarlatinal 
miasm, you will see that a gradation exists in nature 
from the mildest to the most malignant, and that the 
external appearances vary with the character of the 
fever. A division of scarlatina into species has been 
made, but remember that it is artificial. Nature creates 
genera and individual cases, but species are the imper- 
fect arrangements of man. With this reservation, I 



SCARLATINA MITIS. 151 

shall avail myself of the threefold division now in gene- 
ral use, and shall treat of the two extreme links in the 
long chain of phenomena, and the intermediate variety 
— that is, I shall describe to you, 1. Scarlatina mitis; 
2. Scarlatina anginosa ; 3. Angina maligna. 

The poison of scarlatina, whatever aspect it subse- 
quently assumes, has a very short period of incubation. 
It invaded my own family in 3 839. Rigors occurred 
to one member of it on the last Saturday in April. On 
Sunday, languor and lassitude, with dryness of skin, 
were the chief symptoms. At six o'clock on Monday 
morning, eruption appeared. On the following Satur- 
day, at two p.m., my eldest daughter sickened, so that 
the incubative period could not have exceeded seven 
days, and was probably only six. Withering says that 
he has known patients begin to complain as early as 
the third day from exposure to the contagion, and I 
cannot contradict the assertion, though I never saw 
incubation so rapid as this. We may fairly state the 
incubative period as varying from four to eight days. 

1. In the mildest form of scarlatina, it often happens 
that the first symptom is the rash. No febrile disturb- 
ance whatever has preceded. More commonly, there 
is a certain amount of fever, the symptoms not present- 
ing any marked characters. Rigors, heat of surface, 
vomiting, restlessness, thirst, languor, lassitude, muscular 
debility, and headache, are the chief complaints. On 
the succeeding day, the rash appears. Some authors 
would persuade us that the rash may be delayed to the 
third or even the fourth day from the rigor. These 
observations, however, made when the diagnosis of 
measles and scarlatina was yet in its infancy, cannot be 
trusted to. 



152 SCARLATINA MITIS. 

The efflorescence in scarlatina mitis is first perceived 
on the trunk, arms, and thighs ; very often nothing 
appears on the face, when these parts are covered with 
eruption. In less than twenty-four hours, it spreads 
over the whole body. Everything is rapid about scar- 
latina — rapid incubation — rapid eruption — rapid course. 
Sometimes the redness is continuous ; but much more 
generally it is distributed in patches of no definite 
shape. The color is a bright scarlet, precisely that of 
the boiled lobster. When closely examined, it is found 
to consist of innumerable small red points, or dots. In 
the greater number of cases, the finger passed over the 
surface is not made sensible of elevation or roughness. 
Sometimes, especially on the breast, and parts kept 
very warm, the feeling of papulae is given. This, how- 
ever, can only occur when there is fever, and sufficient 
force in the heart's action to distend the cutaneous 
capillaries. In the mild form of scarlatina I am now 
describing, this will not often happen. The redness 
of scarlatina, like that of erysipelas, disappears on 
pressure. 

[The color of scarlet fever has long been described as uniformly spread 
over the surface, as if the part had been rubbed over with the juice of 
raspberries — but this requires some modification. It is not uniform as 
to tint, but is composed of a bright red layer, on which are scattered 
great numbers of very small points of a deep red color, which give the 
eruption a markedly pointed aspect. These two shades of redness vary 
in intensity in different cases, and the predominance of intensity of the 
one or the other gives the surface a brighter or a deeper tint. Towards 
the close of the eruption, the more uniformly diffused layer gradually 
fades, while the red points retain more of their original color, and this 
gives the surface, during this state, a punctated appearance, the distribu- 
tion of which is regular, and has been compared, as far as arrangement 
of the points is concerned, to the granite of painters. This appearance 
sometimes exists during the whole course of the disease. In measles, 



SCARLATINA ANGINOSA. 153 

on the contrary, besides the decided difference in hue, the spots are 
always irregular, without symmetry, and differ in shape, size, and eleva- 
tion. This is especially evident during the decline of the eruption. 
Hence, regularity is a characteristic mark of scarlatina, and irregularity 
o( measles.] 

For twenty-four hoars the child is restless, and refuses 
his food. On the third clay you will find him sitting 
up with his toys. The rash is receding. In two days 
more, the little patient is convalescent. I have often 
examined the throats of children affected with the 
scarlatina mitis, and not seen the slightest trace of 
angina. The poison, therefore, may circulate without 
any throat affection. Well might Sydenham call this 
a disease in name only ; it is nevertheless worthy of 
your study, in order that you may trace the steps by 
which it ascends into the malignant cynanche. 

2. I now come to the scarlatina anginosa, the puni- 
tive type of the disease, or that from which all the other 
varieties diverge. It is, as might hence be presumed, 
by far the most frequent form in which the miasm 
developes itself. Scarlatina anginosa is a disease which 
more than any other that I know of will call into play 
your pathological learning, and all your therapeutical 
skill. It is a disease which may be materially aided by 
medical art. It is a disease in the management of 
which medical men are more apt to differ than perhaps 
any other. It is, lastly, a disease which, from its 
rapidity, leaves you little time for reflection. You must 
have studied it well beforehand, and determined how to 
act in cases of emergency. 

A dry detail of the successive symptoms that will 
meet your observation in the course of scarlatina angi- 
nosa, varied as they are by season, habit of body, 



154 CHARACTER OP ACCOMPANYING FEVER. 

climate, and epidemic character, would profit you but 
little. I shall rather direct your attention to the struc- 
tures and organs affected, and thus associate symp- 
tomatology and pathology. Remember, that in this 
complaint you have four classes of symptoms — 1. 
General fever or pyrexia ; 2. affection of the skin and 
cellular membrane ; 3. affection of the mucous mem- 
branes ; 4. affection of one or more of the great viscera 
— the brain, lungs, or heart. 

(1.) The accompanyiug pyrexia may be, as I have 
already said, either inflammatory or typhoid. In the 
majority of cases, the inflammatory character prevails, 
the heat of skin being more remarkable than in any 
other known malady ; it gives to the hand the feeling 
of scorching. The heat indicated by the thermometer 
often rises to 104, and Dr. Currie says he has seen it 
at 112. The body is living in a furnace of its own 
making. Let not this circumstance pass unnoticed by 
you. The human body is prepared for a heat of 96. 
Its functions then flourish ; but it will not bear to have 
its internal heat much lowered, nor materially raised. 
A heat of 105, 108, or 110, no system can long with- 
stand ; it burns and dries up everything ; it kills the 
cuticle and the hair, injures the delicate structure of the 
eye and ear, deranges the liver and the brain. I attri- 
bute a large share of the evils of scarlatina anginosa to 
the intensity of the animal heat. The blood is not 
always buffy in scarlatina, although the skin be so hot, 
and the pulse rapid ; there is febrile tumult, but not 
inflammation. Inflammation may supervene, but the 
pulse will then be not merely frequent, but hard and 
incompressible. 

[It may probably with safety be said that, at the present time, and 



CHARACTER OF THE ERUPTION. 155 

for several years past, in this country, the type of scarlatina has been 
decidedly tvphoid in its character. It is comparatively rare that we 
find that great heat of shin described by our author, as well as by 
others, as accompanying this disease. The temperature, even in this 
form, is not unfrequently about natural, and sometimes even below this 
standard. With this temperature of the skin, an anginose affection of 
the worst kind is very often associated.] 

The true character of the pulse in scarlatina is rapid, 
seldom less than 120 ; the tongue is white ; and as the 
mucous covering of the tongue is affected, like other 
mucous surfaces, with eruption, so the red and elongated 
papillee protrude through the fur, or diseased secretion 
of the mouth, presenting that peculiar appearance called 
the strawberry tongue. Sometimes it is purely red. 
The other febrile symptoms are the same in kind, but 
exceed in severity those of scarlatina simplex. The 
headache is more pungent, and often accompanied with 
delirium. Muscular pains are severe, and the back of 
the neck is often very stiff. There is a feeling of ten- 
sion and fulness in the fingers, evidently from the force 
of the blood impinging on the extreme capillaries. 

(2.) But to pass to the affection of the skin and sub- 
jacent cellular membrane. The rash is vivid in color. 
I once saw it elevated in circular patches, and some 
physicians called it urticaria rubra febrilis ; but it 
was genuine scarlatina, with sloughy throat. Nothing 
is more desirable than that the eruption should be 
accompanied by a moist state of the surface. There 
is then, as we might reasonably expect, much less risk 
of visceral congestion. The determination of blood to 
the skin is sometimes so great, that miliary vesicles 
appear interspersed among the patches of efflorescence 
(especially on the breast). This variety has been called 
scarlatina varioloides. With ordinary care, however, 



156 CHARACTER OF THE ERUPTION. 

this will never happen. It is attributable to the nimia 
diligentia either of the nurse or of the doctor, of which 
Sydenham complains. Very often the rash recedes for 
a few hours, and then recurs. Sometimes it appears 
only partially, as on the thighs ; white blisters some- 
times accompany or succeed the rash. 

It is very common to see the cellular membrane, 
especially that of the neck, taking on a kind of inflam- 
matory action. The fingers stiffen ; the neck swells ; 
the parotid glands enlarge ; the jaws are with difficulty 
opened. 

[MM. Barthez and Rilliet mention six to eight days as the ordinary 
duration of the eruption of scarlet fever in its normal form. They say 
that it requires a longer period to develope itself than that of measles ; 
and persists longer at its maximum, that is, 24, and even 48 hours. 
They have seen the eruption of scarlet fever last only five days, and have 
also seen it last seven, eight, or even ten days ; but never beyond ten 
days. (Mai. des Enfants, t. 2, p. 5*78.)] 

(3.) The condition of the mucous structures of the 
nose, mouth, palate, and larynx, will demand a much 
more extended investigation. 

Sometimes the very first intimation of the real nature 
of the disease is given by a feeling of roughness of the 
throat, and some pain in deglutition. On examining 
the fauces, the palate, uvula, and tonsils appear red and 
swollen ; and should the fever be active, portions of 
coagulated lymph will be seen effused. These are 
often mistaken for ulcers ; but in many most severe 
cases of anginose scarlatina there is no actual breach of 
surface — only excessive engorgement, with effusion of 
lymph. 

Deglutition is now so painful, that the patient will 
rather suffer thirst than attempt to quench it with the 



AFFECTION OF THE THROAT. 157 

certainty of excessive pain. Be on your guard when- 
ever excessive pain occurs, whether it be in pleurisy, 
jaundice, enteritis, or scarlatina. Remember that death 
maj he the consequence of excessive pain (as in cru- 
cifixion, or the torments of the Inquisition), or, if not 
death, at least serious mischief. In the case of angina, 
excess of pain is followed by extension of inflammation 
to the cellular membrane subjacent to the ear, and to 
the brain. 

It is often difficult to examine the state of the throat 
from the extent of cellular inflammation, but you may 
always form a good judgment of what is going forward 
there by taking as your guides the pulse, and the 
degree of pain in deglutition. That actual ulceration 
does take place in a certain proportion of cases is unde- 
niable, but the former is the more frequent pathological 
condition. I remember seeing a young lady many 
years ago (Miss E. H.), of exceedingly full habit, where 
the determination of blood to the throat was so exces- 
sive that respiration became impeded; the pulse began 
to give way ; and timely scarifications alone saved the 
patient's life. 

^Yhile all this is going on in the throat, the mucous 
membrane of the nose becomes involved. An acrid 
sanies, or ichor, begins to flow from the nostrils. The 
membrane itself appears red and swollen. The sense 
of smell ceases. Inflammation next extends alone; the 
Eustachian tube to the inner and outer ear, An acrid 
discharge, sometimes of a purulent character, distils 
from the ear. The ear is painful. The inflammation, 
if intense, may destroy the interior structure of the ear. 
The ossicula audit us may slough away, the tympanum 
fill up with granulations, and total deafness ensue. 



158 IMPLICATION OF THE EYE. 

But this is not all, nor a tithe of the mischief which 
may take place while the scarlatinal poison is in pro- 
cess of concoction, and struggling, like a giant in prison, 
to work its way out. The eye may become affected, 
and two things may here take place, both requiring 
your attention. The eye itself may take on inflamma- 
tion, and this, if neglected, may go on to actual destruc- 
tion of one or both eyes. In 1832, at the late Sir 
David Berry's, I played a game of chess with Mr. Sey- 
mour, who lost both eyes by this disease. He had been 
seized with an intense form of scarlatina anginosa, at a 
village in the west of England, where the medical man 
wanted knowledge to guide him in the required treat- 
ment. This young man ought to have lost thirty 
ounces of blood from the arm. He was never bled at 
all. The poison, raging uncontrolled, destroyed both 
eyes. 

But further; the inflammatory action may lay hold, 
not of the eye, but of the cellular substance within the 
orbit in which the eye lies imbedded. I have never 
seen this described, and have seen but one case of it, 
that of Mr. Hobson, Surgeon, of Great Marylebone 
street. The ear was here first affected, then the cellu- 
lar membrane of the orbit. The eye was saved only 
by the most vigorous measures — Weeding, cupping, 
physicking, and starving, continued for many weeks, so 
difficult was it found to subdue an inflammatory dispo- 
sition once set up in this structure. Had it been small 
pox instead of scarlatina, where the disposition of 
vessels to pustulation is so strong, nothing could have 
prevented abscess. I was assisted in the management 
of this most difficult case by the late Dr. Warren, and 
Mr. Alexander of Cork street. 



CELLULAR COMPLICATION. 159 

The extension of inflammation to the larynx is next 
to engage our attention. This, too, has received but 
little notice from authors. In November, 1842, I was 
called in to witness the sudden extension of the angi- 
nose inflammation to the larynx. The croupy respira- 
tion was soon succeeded by convulsions, and the child 
rapidly sank. 

(4.) So much for the implication of structures situate 
near to the fauces, and suffering by virtue of their proxi- 
mity to the primary seat of disease. I must now advert 
to the more serious implication of deep-seated and vital 
organs. Mr. Dry, of Tottenham Court-Road, a man 
in the prime of life, of good constitution, took scarlet 
fever in November, 1842. When I first saw him, the 
rash was abundant, and the throat was evidently the 
seat of intense inflammation, although from cellular 
complication it was difficult to examine it. Above all, 
the brain was affected. The patient had got out of 
bed, and was crouching down in a corner of the room 
in a state of high delirium. The eye was suffused. 
The skin was cooled down by exposure to the cold air. 
The state of delirium continued many days, but was 
ultimately subdued. 

Sometimes affection of the brain shows itself with 
less of violence. My eldest girl, during her illness, con- 
tinually repeated the Lord's prayer. These more 
urgent symptoms will sometimes show themselves very 
unexpectedly. Never, therefore, be thrown off your 
guard by the apparent mildness of the- symptoms for 
the first two days. The third is the day of danger, 
when the rash begins to subside, and when the poison, 
still active and driven from the exterior, vents its fury 



160 IMPLICATION OF THE HEART. 

on some internal organ. In a few hours, irreparable 
mischief may be done. 

The lungs are sometimes the seat of inflammatory 
engorgement. I attended,* many years ago, in Broad 
street, Golden square, a young man with scarlatina, where 
urgent dyspnoea and distress about the prsecordia indi- 
cated a gorged state of the lungs or great vessels about 
the heart. Timely venesection saved his life. That 
an affection of the heart, particularly of its interior 
structures, often complicates the phenomena of scarlet 
fever, I cannot have the least doubt. Mr. Snow pub- 
lished cases of complication of pericarditis with this 
disease several years since, and Dr. S. S. Alison has 
more recently directed attention to the subject. Mr. 
Snow conceives the pericarditis to be the result, not of 
the fever, but of the renal disease which succeeds to it, 
and which may give rise to pericarditis, wholly inde- 
pendent of the previous occurrence of scarlatina. This 
complication has also been mentioned by Dr. Golding 
Bird and by several other writers. The intensity of 
the febrile action, the highly oxygenated character of 
the blood, and the increased temperature at which it 
circulates, would lead us to expect such complication. 
The frequency of consecutive dropsy corroborates the 
same pathological doctrine. I may mention one 
strongly marked case, though, in so doing, infandum 
renovo dolor em. A lady was seized with scarlatina at 
the period of parturition. The labor was long and 
severe. She perspired profusely. The heart labored 
violently. The next day scarlatina appeared. The 
heart, exhausted by the preceding efforts, gave way, 
and in about fifteen hours from the appearance of erup- 



ANGINA MALIGNA PUTRIDA. 161 

don, became engorged. A frightful feeling of suffocation 
supervened, and the pulse for a few minutes was imper- 
ceptible at the wrist. This feeling subsided, but the 
heart never regained its natural condition. Dyspnoea 
increased, and in twenty-four hours more, the blueness 
of countenance and incipient delirium showed that the 
lungs were implicated, and that waves of ill-oxygenated 
blood were permeating the brain. Twelve hours longer 
of this semi-asphyxiate state closed the sad and painful 
scene. 

3. The angina maligna putrida (the ulcerous sore 
throat of Fothergill, the cynanche maligna of Cullen) 
next claims vour attention. Bear in mind, that in 
nature, the type last described slides into this, the fever 
gradually losing its inflammatory, and assuming more 
and more the typhoid character. 

The initiatory symptoms of the malignant scarlet 
fever are distinguished from those of the other varieties 
only by their intensity. An irritable state of the sto- 
mach and bowels, vomiting, and diarrhoea, are frequent 
occurrences. Headache, pain of the back, precordial 
oppression, and stiffness of the neck, are present in con- 
siderable severity, with great dejection of spirits. The 
pulse is small and flattering. The eyes appear heavy 
and suffused. There is great debility. The patient 
lies on his back and talks in a whisper. 

The poison first localizes itself in the throat, which, 
on inspection, appears swollen and livid. A disagree- 
able fcetor is perceived in the breath, which rapidly 
increases. Ash-colored sloughs occupy the tonsils. 
Ulceration and often extensive gangrene destroy a large 
portion of the mucous membrane. The voice becomes 
hoarse and hollow, and respiration is performed with a 

11 



162 SCARLATINA WITH COLLAPSE. 

noise like that of one strangling. Hence the Spanish 
name for the disease, garotillo. The throat is clogged 
with a viscid phlegm. The nostrils pour forth an abun- 
dant and acrid sanies, followed by excoriation of the 
lips and ulceration of the angles of the mouth. 

Delirium, often of a very fierce and unrestrainable 
kind, seizes the adult. I have seen two patients in this 
disease in the most raging phrensy — jumping out of 
bed, naked, and literally dying on the floor of the 
chamber. No spectacle more awful can be witnessed 
in Egyptian plague. 

[Dr. Cathcart Lees mentions [Dublin Med. Press, July 3, 1850) a 
peculiar form of delirium resembling delirium tremens, and successfully- 
treated by opium, which he thinks has not been sufficiently noticed by 
authors on this subject. In one case, in a very old person, in which he 
was unwilling to give opium, stimulants were used with success. 

The late Dr. T. F. Cornell, of this city, described two forms of 
delirium in scarlet fever which had come under his observation requiring 
stimulants ; one form in which they should be gradually but perseveringly 
administered, and another in which they should be freely given from 
the beginning, and cites cases in illustration. 

He also fully recognised as a third form, that depending upon an 
inflammatory state of the brain, and requiring antiphlogistic treatment. 
New York Jour. Med. and Surg., Jan. and April, 1841.] 

In some instances the bronchi become congested, and 
difficult breathing is added to the other troubles. In 
another class of cases, the mucous membrane of the 
stomach and intestinal tract receives a large share of the 
febrile impetus. Diarrhoea (scarcely to be restrained), 
with hiccup, distension of the abdomen, ischuria renalis, 
and an extreme sense of exhaustion, characterize this 
most formidable variety of the disease. In the most 
aggravated of all the cases, an cedematous condition 
of the extremities, a bloated and cadaverous aspect of 



SCARLATINA WITH COLLAPSE. 1G3 

countenance, excoriation of the arms and buttocks, a 
hard, dry, and brown tongue, precede the fatal event 
All the circumstances conspire to show T the awful 
derangement taking place in the nervous and circulating 
system through the intensity of the generating poison. 
The blood collects and stagnates in the mucous mem- 
branes of the whole body (thoracic and abdominal), as 
well as in the liver ; and that blood is of the most 
depraved and vitiated quality. Such blood permeating 
the brain, liver, and heart, destroys their functions, and 
death ensues. You may examine the body, but the 
precise cause of death is not thereby manifested. You 
will find probably great destruction of the throat by 
sloughy ulceration or gangrene — turgescence of all the 
mucous membranes — engorgement of the substance of 
the lungs, or liver, or both — effusion of a bloody sanies 
into one or more of the great serous cavities, but the 
condition of the blood is the real cause of death. The 
patient dies of acute malignancy. 

It is encouraging for you to know T that bad as these 
cases are, nature does not always give way under them. 
Dr. Huxham relates an extraordinary instance of reco- 
very under circumstances apparently the most hope- 
less. I'ou will naturally ask, what becomes of the 
skin during this burst of gangrenous angina with 
cerebral complication, gastro-enteric inflammation, and 
hepatic congestion 1 I will tell you. In some cases 
there is considerable efflorescence, but the color is no 
longer scarlet. It is livid. It appears and recedes. It 
is accompanied with itching, and occasionally petechias 
appear, interspersed among the more vivid patches of 
eruption. 

There are cases, very sad ones, occurring both to 



164 SEQUELAE OF SCARLET FEVER. 

adults and children, where no affection of the skin takes 
place at all. Some years ago, I attended, with Dr. 
Nevinson, Mrs. Mason, of Great Marylebone street, and 
her two grown-up daughters. In each of the three 
cases the nervous system was utterly prostrated, or in 
the state of collapse. There was no violence, no deli- 
rium, no rash, no struggling for breath ; but the pulse 
was small, the skin cold, and the whole system depressed 
by the intensity of the poison. Neither wine, nor 
brandy, nor capsicum, could put life into them. They 
sank, one after another, without any attempt to rally. 
It was difficult to believe the disease scarlatina, but the 
eldest son took it in the usual form, recovered, and put 
that matter beyond doubt. 

I proceed next to describe the sequela? of scarlatina, 
as well of the mild as of the anginose and ulcerous 
kind. The very mildest form of scarlatina simplex is 
not free from the risk of some unpleasant sequelae. 
That which is most usually seen is a febricula, with 
swelled glands of the neck, and discharge from the ear. 
The skin is hot, the tongue white, and the alvine secre- 
tions depraved. 

1. When there has been any serious anginose affec- 
tion, the cellular membrane of the neck will often take 
on inflammation. Erysipelatous redness of the neck, 
with great hardness and swelling, are perceived. The 
cellular tissue sloughs, and this sloughing, if extensive, 
brings life into hazard, especially in infants, where the 
vis vitse is low. The danger is less in adults. On the 
15th December, 1842, I attended, with Mr. Squibb, a 
child who died in this state, with accompanying coma, 
who had struggled successfully through the first period 
of the disease. Suppuration of the cellular membrane 



SEQUELAE OF SCARLET FEVER. 165 

of the neck is often so extensive that long and deep 
incisions into the neck are required to afford the neces- 
sary vent to the sloughs. I once saw abscess extend to 
the body of the parotid gland. 

[Death is also sometimes caused by haemorrhage from abscess of the 
neck following scarlet fever. 

A case of ulceration of the internal jugular vein, with a description of 
the parts after death, is given by Mr. Barret, in London Lancet (Amer. 
Repub.), June, 1847 ; and also a case of ulceration of the same vein 
and of a branch of the subclavian, in a child eight years old, by Dr. R. 
J. Hale, in London Jour. Jfed., Aug., 1850, p. *720. 

An interesting case of an abscess opening behind the ear in scarlet 
fever, in which profuse haemorrhage was first restrained by compressing 
the artery with the ringer, and afterwards by applying creasote, and 
with final success, is contained in the prize essay on this disease, by Dr. 
P. AY. Ellsworth, of Hartford (Conn.), published in Boston Med. and 
Surg. Jour., 1846, in which paper reference is also made to a case of 
ulceration of one of the jugular veins, which proved fatal, in the same 
neighborhood. 

Abscesses sometimes form in different parts of the body, besides the 
neck, as a sequel of this disease.] 

2. Desquamation of the cuticle is quite pathogno- 
monic of scarlatina. It is hardly ever absent. In all 
bad cases, the hair comes off too, as indeed it does after 
all long fevers, accompanied (as all long fevers are) 
with dryness and great heat of skin. The nails are 
sometimes thrown off, and some cabinets contain gloves 
of cuticle and nail. It is a curious speculation whether 
this destruction of parts ends with the cuticle, whether, 
in fact, portions of other structures may not be killed in 
like manner as the cuticle, and regenerated during the 
convalescence. 

When scarlet fever attacks a child between the ages 
of 3 and 7, while the second set of teeth is in process 
of formation, it very frequently happens that their 



166 SEQUELiE OF SCARLET FEVER. 

structure is materially weakened and injured. These 
teeth in after life appear dark and imperfect, and are 
lost at a very early age. The same thing is true of 
other severe maladies, especially of the exanthematic 
kind, affecting young children. 

The whole process of desquamation requires careful 
watching. The period is one of low fever, often tend- 
ing to inflammation. The urine is scanty and high 
colored during its progress. The tongue is white, the 
pulse quick, and the rest disturbed. Purgatives and 
saline draughts are often requisite throughout the whole 
period. The desquamative stage begins about the 
fourth or fifth day, and may continue for three weeks. 
German physicians often confine their patients to bed 
during desquamation, so conscious are they of the 
necessity of precaution at this period. 

In the progress of this secondary or desquamative 
fever, inflammation may invade any of the great viscera, 
especially if the constitution be weak, and the contrac- 
tile power, or tone of the vessels, small. Acute pneu- 
monia or peritonitis may thus superveue, and prove the 
immediate cause of death. 

3. In some cases, a low degree of mucous enteritis 
accompanies the decline of scarlatina. The patient 
complains of exceeding languor and lassitude, and total 
loss of appetite. Diarrhoea is present, and the body 
emaciates. The tongue is red and superficially ulcer- 
ated ; the angles of the lips excoriated ; the verge of 
the anus beset with eczematous vesicles. The mucous 
membrane of the bowels is tender, and is thrown into 
spasm and disturbance by the simplest food. Griping, 
therefore, is complained of, and a general soreness of 
the belly. All this may, and frequently does (in fever), 



SEQUELAE OF SCARLET FEVER. 167 

depend simply on congestion. In bad cases, the 
membrane ulcerates, and much blood appears in the 
motions. Death may ensue, for the repair of such injury 
is difficult. 

4. The true debility that sometimes succeeds scarla- 
tina deserves mention. The muscular power is every- 
where enfeebled. The slightest exertion fatigues. The 
heart participates in this general debility, and frequent 
syncope occurs. The clean tongue distinguishes this 
condition of the frame from secondary fever. 

5. The next of the sequelae of scarlatina is dropsy. 
Much has been written on this interesting subject, which 
might well occupy, not the end of a lecture, but a lec- 
ture itself. I will state a few of the circumstances best 
ascertained regarding scarlatinal dropsy. It will occur 
in the apparently mild, oftener perhaps than in the 
severe cases. It may show itself at any period from 
the tenth to the thirtieth day from the recession of 
eruption. I do not pretend always to anticipate when 
it will occur, but I know when it will not occur. It 
will not occur when the pulse falls to the natural 
standard on the tenth day, and becomes soft, with a 
clean state of tongue, an abundant clear urine, and a 
natural aspect of countenance. But it is very likely to 
happen to him whose pulse after the twelfth day of 
fever remains quick and sharp, and whose tongue con- 
tinues obstinately white, where sleep is disturbed, and 
the skin is dry, and a scanty urine becomes turbid on 
cooling. Such persons remain languid and weak after 
scarlet fever, and their appetite does not return. If 
tonics are given to improve the appetite and recruit the 
strength, secretion is still further checked, and the pro- 
bability of supervening dropsy increased. In a large 



168 SCARLATINAL DROPSY. 

proportion of such cases, the urine is loaded with albu- 
men, and of low specific gravity. 

This circumstance has induced some pathologists in 
recent times to connect scarlatinal dropsy in an especial 
manner with an affection of the kidney, congestive or 
sub-inflammatory ; and undoubtedly this is an import- 
ant addition to the pathology of scarlatina. Dr. James 
Miller, in a work entitled, " The Pathology of the Kid- 
ney in Scarlatina," considers renal implication as an 
important feature in certain cases, even from the outset. 
He believes that the scarlatinal miasm fixes itself, occa- 
sionally, on the kidney as it does on the mucous 
textures of the throat, and that the development of this 
renal complication gives a character to the subsequent 
phenomena, leading more especially to dropsy and con- 
vulsion. These cases he proposes to distinguish by the 
title of Renal scarlatina. The occurrence of bloody 
urine in certain cases of scarlatina proves that the 
blood-vessels of the kidney are sometimes highly con- 
gested. In a case seen by me in 1848, and recorded 
in the first volume of the London Journal of Medicine 
(p. 451), the left kidney ultimately took on inflamma- 
tory action, and an abscess was found, after death, 
imbedded in its substance. The frequency of dropsy 
as a sequel in scarlatina, and its rarity in the secondary 
stages of small pox and measles, admits of a satisfactory 
explanation on the pathological principle so ably illus- 
trated by Dr. Miller. 

[Albumen is not always present in scarlatinal dropsy, as our author 
intimates. In 60 cases out of 100 in an epidemic in Berlin, in 1840, 
in which the urine was tested, Dr. Philipp never detected the presence 
of albumen by heat alone, and in only a few cases by nitric acid. 
Dropsy invariably occurred in cases which were not carried off early, 



SCARLATINAL DROPSY. 169 

and began to appear, in a more or less severe form, from the twelfth day 
to the fourth or fifth week after desquamation had commenced. Not 
one case of dropsy proved fatal. [Brit, and For. Med. Rev., Jan., 
1841.)] 

Scarlatinal dropsy may assume any of the usual forms 
— anasarca, ascites, hydro thorax. Anasarca is infinitely 
the most common, perhaps in the proportion of ten to 
one. Sometimes the three are associated. We may 
then rest assured that the heart has become implicated 
in the course of the disorder, and that some serious 
impediment to the free course of the blood exists within 
or about the heart — probably a deposition of lymph 
about one or more of the valves of the heart, which 
careful auscultation will detect. These cases may 
nearly be despaired of. I have seen simple ascites suc- 
ceeding scarlatina, depending upon inflammation of the 
peritoneal covering of the liver, and yielding to leeches 
and saline purgatives. 

[Dropsy may supervene in scarlet fever in two different ways : — 

1. Suddenly, distending the cellular substance of the whole body, 
and extending even to the cavities, within twenty-four or thirty-six 
hours, with fever, and almost entire suppression of urine, and very rapid 
pulse. This form occurs quite as often, and perhaps more so, after mild 
attacks of the disease. 

2. Gradually, with little or no fever, first showing itself by puffiness 
about the eyes, or swelling of the whole face, or of the ankles, or of all 
these parts at the same time.] 

The anasarca succeeding scarlatina is curable in a 
large proportion of cases — a circumstance which ren- 
ders it probable that the condition of the heart, kidney, 
or other viscera giving rise to it, is one of congestive 
rather than of pure inflammatory action. 

Tt was a favorite notion of physicians in times past, 
that scarlatinal dropsy depended on debility of the capil- 



170 SCARLATINAL DROPSY. 

laries, and was to be combated by tonics and wine. 
This doctrine must have been encouraged by the results 
of practice, or it never could have enjoyed such popu- 
larity ; and this is true. I have seen weakly children 
become anasarcous after scarlatina, and recover by the 
aid of wine and bark. But very many cases so treated 
would be exasperated. The urine would become still 
scantier, still deeper colored. The oppression of the 
breathing would augment, and they would die at length 
with the thorax full of water. 

Hydrothorax succeeding scarlatina in the adult, still 
more commonly in children, may advance without 
attracting attention. Some years ago, a gentleman 
having passed through scarlet fever, began to conva- 
lesce, but his recovery was neither rapid nor satisfac- 
tory. Symptoms were not urgent, and attracted no 
particular notice. He walked out one morning to his 
club-house. On returning, he fell, and was car- 
ried home a corpse. His chest was found full of 
water. 

Therefore, watch carefully the secondary fever of 
scarlatina. Watch the period of convalescence, even 
though no fever developes itself. Convince yourselves 
that the kidneys secrete urine of healthy, and not of 
albuminous quality. If fever hangs about the patient, 
and ill- defined symptoms harass him, keep your eye 
and ear upon the chest, so that you may early detect 
any unusual murmur indicative of cardiac disease, or 
any evidences that the lungs are congested, or the 
pleural sac distending with fluid. See that the pulse 
be soft and the tongue clean, ere you take your leave. 
" Aliter male consules nomini tuo" as Baglivi observed 
150 years ago. Without aid judiciously administered, 



SCARLATINAL CONVULSIONS. 171 

a system suffering under the secondary fever of scarla- 
tina will not regain its healthy action. 

[For a summary of the views of different pathologists in relation to 
dropsy following scarlet fever, see xippendix H.] 

6. The last of the sequelae of scarlatina, and happily 
the rarest, is convulsion. Not more than one out of 
eighty cases will be found thus affected. Convulsion 
may accompany the development of fever, or it may 
be deferred, and occur unexpectedly, when a hasty 
observer might consider convalescence as confirmed. 
The period of its accession, therefore, may vary from 
the third to the fortieth day from the invasion of fever. 
The pathology of scarlatinal convulsion has not yet 
been investigated with all the accuracy which is desir- 
able. It appears to be owing, in some cases, to disor- 
ganizing processes going on in the brain. In others, it 
perhaps depends on the condition of the blood which 
the heart is propelling towards the brain. Scarlatinal 
convulsion is accompanied by a buffy state of the blood 
and inordinate action of the heart. Convulsion some- 
times succeeds to dropsy, and the two affections are 
pathologically allied. The occurrence of convulsion in 
scarlatina always betokens great danger. I have notes 
of seven cases, five of which died, and two recovered. 

[Dr. Robert Barnes has called attention to a muco-purulent discharge 
from the vagina in scarlatina, which he considers as important in rela- 
tion to forensic medicine, and which he supposes to be of rare occur- 
rence. (Lond. Med. Gaz., July 12, 1850.) 

Dr. J. R. Cormack has published a paper on this affection in the 
same Journal (August, 1850), in which he states that it is less uncom- 
mon than has been supposed, and that, in an epidemic of scarlet fever 
in 1848-49, in 23 female patients under his care, all of whom were 
cleanly and well nursed, there were 12 cases of well marked vaginitis. 
Of these 23 patients, two only were above fourteen years of age, and 



172 SEQUELAE OF SCARLET FEVER. 

these were respectively 26 and 28 years of age, and both married, and 
both of these had acute vaginitis much more severe than any of the 
children. He says that he was so much impressed with the importance 
of averting or preventing this affection, that, in every female patient, he 
directed careful ablution of the parts, at least twice every twenty-four 
hours. He regards it as " a not unlooked for extension of the exanthe- 
matous inflammation of the skin, analogous in its nature to what is 
often met with in the mucous linings of the nose, ear, air passages, and 
intestinal canal." 

"Wry neck, or contraction of the sterno-eleido-mastoid muscle, is 
another, and occasionally very troublesome sequel of this disease. It 
sometimes goes off spontaneously in a few days, and at other times lasts 
for months, and even for years, and can then only be relieved by an 
operation. 

Dr. Golding Bird alludes to peculiar pains, at first sight apparently 
of a rheumatic character, limited almost entirely to the lower limbs, as 
following scarlatina — not constant, but apparently of a spasmodic or 
cramp-like character. (Guy's Hosp. Hejx, April, 1845.) 

The frequency of occurrence of sequelae in scarlet fever is said by Dr. 
Bird to be in the inverse ratio of the severity of the attack.] 



LECTURE VIII. 

STATISTICS, PATHOLOGY, AND MANAGEMENT OF 
SCARLET FEVER. 

Statistical details showing the prevalence of scarlatina in England, the 
proportion of severe to mild cases, and the per centage of mortality. 
Diagnosis of scarlatina from measles. Pathology of scarlatina. Laws of 
the scarlatinal miasm. Question of spontaneous origin. Recurrence of 
scarlatina. Cause of the diversity of its aspects. Management of scarla- 
tina. General principles. Employment of emetics. Cold affusion. 
Blood-letting, general and topical, purgative medicines, stimulants, and 
cordials. Bark. Local treatment of the angina. Management of scarla- 
tinal dropsy. 

Scarlet fever is undoubtedly an increasing malady in 
this country. The details of its ravages, however, in 
the last century, are not well known, for the deaths by 
scarlet fever are mixed up in the old bills of mortality 
with measles and quinsy. Still the united number was 
small, and bears no comparison with the results of recent 
observation. The amount of mortality occasioned by 
scarlet fever throughout England at the present time 
is really appalling. Mr. Farr, in his third and fourth 
Keports, has given a most instructive series of tables 
showing the deaths by scarlet fever (in each of the 324 
districts into which England and Wales have been 
subdivided) for three years and a half, divided into 
fourteen quarterly periods, extending from July 1, 1837, 
to December 31, 1840. The general results of this 
gigantic investigation appear in the following brief 
summary : — 



174 



STATISTICAL DETAILS OF SCARLATINA. 



Table shotting the Deaths by Scarlet Fever throughout England and 
Wales, within Fourteen Quarterly Periods, extending from 1st 
July, 1837, to 31st December, 1840. 



QUARTERLY PERIODS. 


1837. 


1838. 


1839. 


1840. 


Jan., Feb., March . . . 
April, May, June . . . 
July, August, Sept. . . 
Oct., Nov., Dec. . . . . 

Total Deaths . . . 


1033 

148*7 


1380 
1104 
1260 
2058 


1655 
1620 
2529 
4521 


4537 
4370 
4874 
6035 


2520 


5802 


10,325 


19,816 



From this table we learn that the ravages of scarlet 
fever have (on the whole) progressively augmented 
from the first to the last of these periods, and that the 
year 1840 exhibits an increase over 1837 of four to 
one. It further shows that the greatest mortality by 
scarlet fever takes place in the last three months of the 
year, and the smallest mortality in the months of April, 
May, and June. This is exactly what Dr. Willan had 
remarked nearly fifty years ago, when watching the 
visitations of epidemic scarlet fever in London. Never- 
theless, you will perceive that the influence of season 
on the mortality of scarlet fever is not very striking. 

[An examination of the months in which 4334 deaths by scarlet fever 
took place in New York, within sixty quarterly periods, during the fifteen 
years from 1830 to 1844 inclusive, shows that by far the greatest num- 
ber of deaths occurred during the months of January, February, and 
March, and the smallest number during the months of July, August, 
and September, the numbers corresponding with these periods 
respectively being 1600 and 665 ; the numbers during the quarterly 
periods of October, November, and December, and of April, May, and 
June, being respectively 1084 and 985.] 

You are not to suppose that the above table exhibits 
a picture of the average mortality in England by this 
disease. The years 1838, '39, and '40 were years of 



PROPORTION OF SEVERE TO MILD CASES. 175 

epidemic prevalence. It is probable that no epidemic 
of similar length and intensity ever before visited this 
country. It began in the metropolis in September, 
1838, and reached its acme with us early in December, 
1S39. In the first week of that month, eighty-two per- 
sons died of scarlet fever in London, being a daily 
destruction of twelve lives. Nine hundred and seven- 
teen persons perished in London by scarlatina during 
the last quarter of 1839. In the whole year the deaths 
were 2500, being four times as many as died of small 
pox, and one-fifth more than the mortality by measles. 

[In New York, the whole number of deaths by scarlet fever from 
1815 to 1828 inclusive, was only 97, while in the succeeding 21 years 
(from 1829 to 1849 inclusive) 5179 fell victims to it. In Philadelphia, 
the number of deaths by it was comparatively small from 1807 to 1831, 
in which year 200 are recorded, and in the following year 307, the 
former sum exceeding by nearly fifty the whole mortality for the 24 
preceding years. It began to prevail extensively in Boston also in 
1831, and has caused a large number of deaths from that time to the 
present] 

The following are the observations of authors on the 
proportion which severe cases bear to the mild — inflam- 
matory, to the putrid. Dr. Willan states that in 1786, 
he saw 39 cases of malignant to 152 of the anginose 
variety (one to four). Dr. Clark, of Newcastle, had 33 
cases of malignant to 73 of anginose (one to two) ; 
and 23 out of 131 (or one in six) had dropsy superven- 
ing. He adds — " Considering the numbers that are 
attacked in too mild a form to seek medical advice, the 
proportion of malignant to mild cases should not be 
rated higher than one in twenty." 

With reference to the per centage of mortality, we 
have sufficient materials for forming a good judgment. 
We lay aside Sir Gilbert Blane's experience, as apply- 



176 



PER CENTAGE OF MORTALITY. 



ing only to picked cases. At Ackworth school, in 
1803, the disease proved fatal at the rate of four per 
cent. Dr. Tweedie informs us that out of 644 cases 
treated at the London Fever Hospital, in the twelve 
years between 1822 and 1833, there died thirty-eight 
(thirteen males and twenty-five females), which is 
nearly six per cent. The rate of mortality at that hos- 
pital varies very greatly, far more than is observed in 
small pox. In 1832, it was as low as one in forty; in 
1829, as high as one in six — an immense fluctuation, 
extending from two and a half to seventeen per cent. 

I am indebted to Mr. Ward, of Bodmin, for the fol- 
lowing : — 

Table exhibiting the Number of Cases of Scarlet Fever occurring at 
Bodmin between June 24 and December 24, 1842, with the Mor- 
tality and Character of the Cases. 



Cases with Eruption .... 
Cases without Eruption . . . 

Total Cases . . . 


Numbers. 


Deaths. 


Rate of Mortality. 


324 

108 


26 
10 


Eight per cent. 
.Nine per cent. 


432 


36 


One in twelve. 



Thirty-nine of the cases followed by dropsy ; five, by convulsions, of 
whom four died. 

The average of these observations gives six per cent, 
as the medium rate of mortality by scarlet fever. What 
a picture may be thence drawn of the actual extent of 
scarlet fever in years of epidemic prevalence ! It shows 
that in London, in 1839, there were 41,650 cases of 
this disease ; while throughout England and Wales, in 
1840, when 19,816 persons died, the total number of 
seizures must have reached the almost incredible num- 
ber of 330,266. 



PER CENTAGE OF MORTALITY. 177 

There are no statistical records to teach us (as in 
small pox) the period of greatest danger; death has 
been said to take place in nine hours. I never saw 
anything so rapid as this ; but I have seen death occur 
on the second day, and frequently on the third. I 
would call sixty hours from the breaking out of the 
rash, the period of greatest danger Many, of course, 
die at a much later period, — on the eighth or twelfth 
day. Dropsy and abdominal complications may pro- 
tract the date of death to a month. 

The proportion of fatal cases occurring at the several 
periods of life (young, adult, and aged) is well illus- 
trated in the registrar general's tables. Out of 345 
cases proving fatal in London during the months of 
January and February, 1840, 326 were children (under 
fifteen), and only nineteen were adults. Out of 2614 
cases recorded by Mr. Fan* in his fourth Report, 2419 
were children, 182 adults, and 13 aged persons. The 
violence of the disease falls therefore on children, as 
compared with grown persons, in the proportion of 
seventeen to one in the first case — of twelve to one in 
the second. 

[Ages of 2614 persons who died of scarlet fever in New York during 
the eight years from 1837 to 1844 inclusive, and of 1974 who died in 
Philadelphia, during nine years from 1837 to 1845 inclusive : — 







New York. 


Philadel 


One year and under, 




. 285 


. 184 


Between 1 and 2 years, 


. 


. 483 


. 363 


2 and 5 " 


. 


. 1214 


. 919 


" 5 and 10 " 


. 


. 460 


. 409 


" 10 and 20 " 


. 


83 


58 


" 20 and 30 u 


. 


. 55 


22 


" 30 and 40 " 


over, 


. 17 


12 


Carried 


2597 


1967 




12 







178 PER CENTAGE OF MORTALITY. 





New York. 


Philadelphia 


Brought over, . 


. 2597 


. 1967 


Between 40 and 50 years, . 


5 


5 


" 50 and 60 " 


7 


2 


" CO and 70 " , 


1 





Unknown, 


4 





Total, 


. 2614 


. 1974 



New York. 


Philadelphia. 


30.12 


40.69 


76.75 


75.49 


97.39 


97.77 


2.60 


2.22 



Table exhibiting the per centage of deaths by scarlet fever at different 
ages to the whole mortality by that disease, in the cities of Glasgow, 
New York, and Philadelphia : — 

Glasgow. 

Under 2 years, . . 35.40 

" 5 ' k ' . . 70.15 

" 20 " . . 97.95 

Above 20 years, . . 2.04 

This table shows a remarkable uniformity in the age at which death 
took place by this disease in these different places. (Proceed, of P kilos. 
Soc. of Glasgow, extracted by Amer. Jour. Med. Sci., Apr. 1845.) 

It will be seen by the preceding tables, that but a fraction of the 
mortality by scarlet fever occurs over 40 years of age, almost one half of 
the deaths taking place between 2 and 5 years of age, although a few 
are recorded between 50 and 60, and one in this city between 60 and 
70 years. Sir Gilbert Blane saw but one case in a. patient over 40 
years of age, and Dr. Copland has seen but one between 50 and 60 
years. Dr. C. Lees had one patient 70 years old with it, and Dr. 
Chapman had one 80 years old. It is also comparatively rare in the 
earliest months of life. 

In some epidemics, the disease is almost confined to patients between 
15 and 25 years of age. 

Scarlet fever would seem to be about six times less fatal among blacks 
in New York than among whites, the number of deaths in proportion 
to the population of the two races, during the eight years from 1837 to 
1844 inclusive, being that of 1 to 76 of the whites, and of 1 to 450 of 
the blacks. In the year 1837, there were only 3 deaths by this disease 
among blacks to 576 among whites. Reference to the note on page 
35 will show that the mortality by scarlet fever was also much less 
among the blacks in Charleston (S.C.) than among the whites, though 
the disparity is much less than in New York.] 

Dw Withering distinctly states, and certainly a gene- 



DIAGNOSIS OF SCARLATINA FROM MEASLES. 1 79 

ral impression prevails, that scarlatina invading adults 
is, ccBteris paribus, a severer disease, and occasions a 
greater per centage of mortality, than when it invades 
infantile life. Whether this be the fact or not, I have 
at present no means of judging ; but for a long time it 
has been known that scarlet fever is peculiarly danger- 
ous when it occurs at the puerperal period. The cir- 
cumstances in which the system is then placed suffi- 
ciently account for the fact : the heat of the body — the 
exertion — the consequent exhaustion ; and possibly the 
peculiar condition of the blood accompanying the puer- 
peral state. All these things naturally tend to augment 
the virulence of fever, whether specific or non-speeific, 
originating at that period. 

I shall not detain you with any remarks on prognosis. 
After the exposition I gave of the character of the 
symptoms in the anginose and malignant forms of scar- 
latina, you cannot fail to perceive both the signs and 
the causes of danger. 

When treating of measles, I mentioned briefly the 
chief points of diagnosis between it and scarlet fever. I 
will now recur, somewhat more in detail, to this subject, 
which, by the way, is very ably treated in Dr. Williams's 
work on the morbid poisons. 

1. Measles and scarlet fever differ in their incubative 
periods; scarlet fever lies latent one week — measles, 
two weeks. 

2. Measles and scarlet fever differ in the periods of 
their eruptive fever. Scarlet fever developes rash in 
twenty-four hours, measles in seventy-two hours, after 
the setting in of fever. 

3. The two diseases differ in the color and aspect of 
the efflorescence. In scarlatina it is bright scarlet ; in 



180 PATHOLOGY OF SCARLATINA. 

measles, it is a dull raspberry red. In scarlatina, the 
eruption is extensive and diffused, brightest on parts 
covered. In measles, it is in patches, brightest on parts 
exposed. 

4. The diseases differ in the concomitant affection 
of the mucous tissues In scarlatina, there is early and 
often serious inflammation and sloughing of the throat. 
In measles, the mucous affection is chiefly in the nose, 
eyes, and larynx. There is no disposition to cynanche 
or its consequences. 

5. The two diseases differ in their secondary actions. 
Scarlet fever is accompanied and followed by phrenitis 
and dropsy ; measles, by pneumonia. 

6. The two diseases differ, lastly, in their tolerance of 
remedies ; measles bears blood-letting well, scarlet fever 
badly. 

[In addition to the diagnostic marks mentioned by our author, may 
be mentioned : 

1. Swelling of the hands and sometimes of the feet, never present in 
measles, and hence of some importance as an external mark. 

2. Character of the desquamation — being in scarlatina in the form 
of flakes of greater or less size, and especially on the hands, from which 
the epidermis sometimes comes off like the fingers of a glove ; while in 
measles it is fine and branny. This point of difference is sometimes of 
importance on account of the sequelae of the two diseases.] 

I come next to investigate the pathology of scarla- 
tina ; to explain to you the laws which govern the 
phenomena of the disease — its rise — its symptoms — its 
varieties — its complications. The subject is one of great 
extent and intricacy, but it is one also of much patholo- 
gical interest, and of some practical importance. 

The notion that scarlet fever was the result of a mor- 
bid poison was one of very early growth. Morton 



PATHOLOGY OF SCARLATINA. 181 

expresses very clearly and pithily the opinions enter- 
tained during the 17th century on this subject: — " The 
proximate cause of scarlatina," says he, "is a poison 
defiling the animal spirits, whose malignity does not 
only overwhelm the spirits in its first attack, but by 
agitating the mass of blood, breaks it down into an acrid 
colluvies more energetically than any other ferment." 

Navier (a French author), who has given the history 
of the epidemic of 1753, goes a step further, and attempts 
to connect this poison with that which occasions the 
distemper of horned cattle — a distemper which prevailed 
in London in 1839, and which has lately devastated 
Egypt " In this bovine epizootic," says Navier, " the 
convalescent beasts lose their hair, and their skin peels 
off. When they die, the viscera are always found 
more or less in a gangrenous state." He gives it as his 
opinion that the contagion of scarlet fever originated 
with cattle, and was by them communicated to man. 
He traces also some connexion between these com- 
plaints and small pox. I mention these circumstances 
because they prove to you how early the attention of 
men's minds was directed to the analogv between the 
diseases of men and cattle, a doctrine which, investi- 
gated by the genius of Jenner, led afterwards to such 
brilliant results. 

Scarlatina is peculiarly the disease of temperate 
climates. It is comparatively rare in Bengal. Dr. 
Jackson, formerly of Calcutta, now of Chatham, informs 
me, that he cannot recall to mind having seen any cases 
in India deserving the name of scarlatina. i have 
never met with any account of the disease as it occurs 
in the black skin ; but perhaps this may be my own 
fault. 



182 LAWS OF SCARLATINAL MIASM. 

[The aid afforded by tint is lost in the diagnosis of scarlet fever in 
blacks, but the characteristic distribution is still preserved, and the parts 
which are the seat of the eruption are marked by a deeper shade of the 
color of the skin, whether that be of a deep black, or of some its modifi- 
cations. The precursory and accompanying symptoms, however, are 
most to be depended upon for diagnosis in this race.] 

America did not receive the contagion of scarlatina 
till the year 1735, as we learn from a curious paper by 
Cadwallader Golden, Esq.* Its progress over that 
great continent was singularly slow, but attended with 
great loss of life. " Like most new diseases," says Mr, 
Kearsley, describing the epidemic that began in 1746, 
" it baffled every attempt to check its progress. Villages 
were depopulated by it, and parents left to bewail the 
loss of all their children." 

[The first appearance of scarlet fever .in New England was in May. 
1*735, at Kingston, an inland town about 50 miles eastward of Boston. 
On the 20th of August of the same year it appeared in Boston, and of 
about 4000 persons who had it, about 1 in 35 died. In the country 
towns the mortality was much greater, from 1 in 6 to 1 in 3 dying of 
it. In Kingston, where the usual annual mortality was not above 9 or 
10, it rose that year to 102. The disease as it prevailed in New 
England in 1735 and '36, was described by Dr. William Douglass, in a 
work published in 1736, and reprinted in the New England Journal of 
Medicine and Surgery, vol. xiv. p. 1. For an analysis of his work, see 
Historical Sketch of State of Medicine, <fec, by John B. Beck, M. D., 
Transac. Med. Soc. State New York, Feb., 1850.] 

Scarlet fever affects the sexes in equal proportions, 
and very remarkably. In 1838 it destroyed, in London, 
747 males, 777 females. In 1839, 1241 males, 1258 
females. Throughout England and Wales, in 1840 
(exclusive of the metropolis), 8927 males, 8935 fe- 
males ! 

* Medical Observations and Inquiries, vol. i. p. 211. 



LAWS OF SCARLATINAL MIASM. 183 

[Of 2614 deaths by scarlet fever in New York, during the eight 

years from 1837 to 1844 inclusive, 13.37 wore males and 1277 females; 
and o( 1974 deaths by the same disease in Philadelphia, during the 
nine years from 1837 to 1845 inclusive, 1008 were males, and 9G0 
females.] 

The infecting distance of the miasm has not been 
investigated ; but it is found that when it invades a 
school, no precautions avail anything towards prevent- 
ing the spread of the infection. This has often been 
proved at the London Foundling Hospital. At Ack- 
worth, in 1803, the contagion lingered in the school for 
four months, in spite of every effort. With regard to 
the susceptibility of this complaint, Dr. Binns tells us, 
that out of 216 scholars at Ackworth school, 184 were 
affected. Dr. Adams remarks that this is a larger pro- 
portion than is commonly found susceptible in districts 
or families. Like all other miasms, that of scarlet fever 
is capable of attachment to fomites, especially clothes. 

[The question is still unsettled both as to the exact period at which a 
patient with scarlet fever begins to be a focus of contagion, and also 
how long he continues to act as such by the secretion of the poison. 

With regard to the first point, Dr. Robert Williams (on Morbid Poi- 
sons) thought that the generation of the poison commences with the 
fever, and before the appearance of the eruption. With regard to the 
second, it was the opinion of Dr. Willan, that children convalescing from 
this disease, notwithstanding every attention to cleanliness and change 
of apparel, are capable of communicating it (especially to other children) 
for two or three weeks after apparent recovery. 

We have always been led to consider the end of the period of desqua- 
mation as the time when the patient ceases to generate the poison, and 
to communicate it directly by emanation from his own person. All 
communication after that period we should be inclined to refer to 
fomites, of the communication of the disease by which means at inter- 
vals of even several months, and at considerable distances,* numerous 
instances are on record.] 

No doubt exists that, in a very large proportion of 



184 RECURRENCE OF SCARLATINA. 

cases, scarlet fever is the produce of a specific miasm ; 
but the question may well arise, whether any combina- 
tion of circumstances can developean eruption possessing 
the characters of scarlatina. I am bound to tell you 
that 1 believe they can. I have seen scarlet eruption, 
in no respect different from that of ordinary miasmatic 
scarlatina, arising from exposure to cold and moisture. 
A young man residing near St. James's Street, some 
years since went down to the Serpentine to bathe. He 
walked in a hurry, plunged in when overheated, and 
two days afterwards I saw him covered with scarlet 
eruption. He had suffered in the same way once before. 
I often see true scarlatinal eruption occurring in the 
progress of the secondary fever of small pox, without 
any grounds for believing that contagion had operated. 
It seems as if secondary fever can develope this eruption 
in the same w T ay as it throws out erysipelas. 

[We should ourselves prefer the application of the term erythematous 
or roseolar, rather than " scarlatinal," to the efflorescence in the preceding 
case, as well as to that sometimes occurring in the secondary fever of 
small pox, produced as the former was by a sudden check of perspiration, 
and belonging, as it does, to analogous farms of eruption produced by 
common causes of disease — restricting the use of the term scarlatinal to 
that form of eruption constituting one of the characteristics of a febrile 
exanthem, which originates in contagion, is governed by fixed laws, 
pursues a definite course, is liable to certain complications and sequelae, 
&c. We should fear lest the use of the epithet scarlatinal in a generic 
sense, to signify different kinds of redness, non-specific as well as specific, 
however close the resemblance between them, would tend rather to add 
to the confusion already too great, which hangs about the nomenclature 
of cutaneous diseases.] 

Thus much I thought it right to say before approach- 
ing the vexata questio of secondary attacks of scarlet 
fever. Observe the conflicting statements of authors on 



RECURRENCE OF SCARLATINA. 185 

this head. Dr. Willan (certainly one of the most acute 
and careful observers of the disease) says, that out of 
2000 eases which he attended, he saw no instance of 
recurrence. Dr. Currie, of Liverpool, who devoted 
much attention to scarlatina, was compelled, by the 
results of long experience, to " renounce the opinion he 
had early imbibed, and to confess that the same indivi- 
dual is liable to scarlatina once only." Sir Gilbert 
Blane, on the other hand, met with one instance of 
scarlet fever occurring thrice, and, as he says, " without 
the least suspicion of ambiguity." Dr. Binns inclines 
to the notion of occasional recurrence. 

Exceptions do occur; nevertheless, the law of ex- 
hausted susceptibility, as Dr. Williams calls it, is very 
strongly marked in this disease. I cannot doubt but 
that a large number of the alleged cases of recurrent 
scarlet fever are cases of lichen ous or urticarial eruption, 
suddenly brought on by cold, or some deleterious article 
of food — cases which have no decided incubative stage, 
which run a premature course, wholly distinct from the 
steady march of a specific anginose fever. Medicine is 
filled to overflowing with false facts of this kind, set 
down without much consideration, and w T ith a scanty 
knowledge of pathology. 

[Dr. Tweedie says that he has certainly met with several well authen- 
ticated instances of a second attack of scarlet fever in the same person. 
(Cycl. Prac. Med., Art. Scarlatina.) 

One case of recurrence of scarlet fever came under the observation of 
M. Rayer during the period which elapsed between the first and second 
editions of his work on Diseases of the Skin. He had met with no in- 
stance of it when the first edition was published.] 

Scarlatina is one of the very few diseases to which 
the foetus in utero is liable. On the 28th April, 1839, 



186 DIVERSITY OF ASPECT. 

my youngest son was born, evidently suffering under 
some form of fever. The throat was affected on the 
following day, obviously from angina maligna. Erup- 
tion was never developed The child drooped, and 
died on the first of May. 

Attempts have been made to produce scarlet fever 
artificially by inoculating with the blood, or with the 
serum of miliary vesicles intermixed with the specific 
eruption. We are informed that scarlet fever, unmiti- 
gated, was subsequently developed. No good could 
have been anticipated from such a measure. 

You see the great diversities in the aspect of scarlet 
fever. Can any explanation of this phenomenon be 
offered which is at all satisfactory 1 Is it attributable 
to the weather, to diversities of individual habit, to di- 
versities in the quality of the contagious miasm 1 Sta- 
tistics teach us that season has nothing to do with it. 
The year 1839 was peculiarly fine, yet in that year 
scarlet fever raged in London like a pestilence. I am 
well aware that bad cases sometimes propagate mild 
cases, and vice versa ; but I cannot shut my eyes to the 
fact, that, on a large scale, you will find mild cases suc- 
ceeding each other, and severe cases producing severe 
cases. I am inclined, therefore, to attribute something 
to the quality of the infective miasm ; but I candidly 
acknowledge the obscurity in which this branch of 
exanthematic pathology is involved, and hope, with 
Huxham, it may hereafter be cleared up. 

The management of scarlet fever, in all its varied 
forms, now demands your best attention. Let us first 
consider the objects which should be kept in view. 1. 
It is your duty to moderate arterial excitement when it 



MANAGEMENT OF SCARLATINA. 187 

runs dangerously high, and especially to lessen the heat 
of the surface. 2. You must support the tone of the 
system, when oppressed or subdued by the malignity of 
the poison. 3. You must obviate local congestions and 
the organic complications which arise in the progress of 
the fever. In these general propositions, all physicians 
will probably agree ; but the difficulty consists in prac- 
tically carrying them out. What are the best means of 
fulfilling these indications 1 How far are the remedies 
to be pushed I These are the pinching questions. Our 
chief reliance, in the management of scarlet fever, is 
placed in the skilful use of one or more of the following 
classes of remedies : — 1. Emetics; 2. cold affusion ; 3. 
blood-letting, general and topical ; 4. purgatives ; 5. 
tonics, stimulants, and antiseptics. They will require 
separate investigation. 

We may begin, however, by getting rid of the mild 
form of scarlatina, which, as Sydenham said, demands 
very little aid from the physician. The cases should be 
watched, lest local congestions arise ; but otherwise, a 
gentle laxative powder, and abstinence from meat and 
beer, are alone required. We may, in the same sum- 
mary way, dispatch those cases which are at the other 
extremity of the chain — the cases of angina maligna 
gangrenosa, with undeveloped eruption, which, from 
the very onset, are characterized by depression, or col- 
lapse of the nervous system. Common sense here 
dictates an early recourse to stimulants — to wine, brandy, 
cordial draughts containing aether, camphor julep, aro- 
matic confection, and tincture of bark, in such quantities 
and doses as the stomach will bear, and the age of the 
patient justify. On this point there is no room for 
doubt or cavil. 



188 PRINCIPLES OF TREATMENT. 

The real difficulty centres in the management of the 
intermediate cases of anginose scarlatina ; and the cause 
of such difficulty is this : — the symptoms indicate high 
arterial action; bat the scarlatinic miasm is very de- 
pressing, and the powers of life often sink, even without 
artificial reduction of strength. Some physicians, there- 
fore, let the arterial action have its full swing, for fear of 
subsequent exhaustion. Others check the first advances 
of the disease, and take their chance of succeeding 
debility. On this I would observe, that no one system 
can be pursued safely. The primary arterial excitement 
must sometimes be your guide. Sometimes your treat- 
ment must be regulated by a consideration of the de- 
pressing nature of the poison, the defective coagulability 
of the blood, and its consequent stagnation in the capil- 
laries, especially those of the mucous surfaces. Further, 
it will often happen that after applying leeches in the 
morning to check cerebral congestion, you must give 
wine in the evening to support the system under the 
exhaustion that ensues. I now proceed- to offer you 
some practical suggestions on each of the several reme- 
dies already enumerated. 

1. Emetics. Dr. Withering imagined, when recom- 
mending emetics in scarlet fever, that he had made a 
great improvement in medicine. He said of them that 
they were the remedies of nature, avoiding equally the 
debilitating effects of blood-letting and the stimulating 
effects of bark — equalizing the circulation, and obviating 
local congestion. There was something more than met 
the eye in this extravagant laudation of emetics. Dr. 
Withering had a crotchet that the scarlatinal miasm 
operated, not upon the blood primarily, but on the 
mucus of the throat ; that here the disease began, and 



EMPLOYMENT OF EMETICS. 189 

from hence was propagated to the stomach and general 
system. Therefore, said Withering, emetics must be 
useful, because they dislodge the vitiated and corroding 
mucus, on which everything hinges. Thus, like other 
physicians before and since, he made practice square 
with theory. That emetics cannot be so very useful as 
Withering represents, must be apparent, when you 
reflect that the cases which set in with vomiting, gene- 
rally end badly. Emetics are never given nowadays 
in the wholesale manner recommended by Dr. Wither- 
ing — viz., " a powerful vomit, repeated, in the worst 
cases, three times in twenty-four hours." An emetic is 
sometimes beneficial at the very onset of fever, to which 
period the use of such a remedy should be restricted. 
Dr. Rush recommended calomel to be added to the 
emetic, the effect of which was to act subsequently on 
the bowels. I have no experience in this practice ; 
which, therefore, I am not prepared to condemn. 

[Emetics are often useful at an early stage of the disease, when the 
tongue is much coated and the breath offensive. Besides removing the 
contents of the stomach, and producing a favorable change in its secre- 
tions, they often improve the condition of the throat, and also doubtless 
do good by equalizing the circulation — but they should not be used 
when there is any decided manifestation of disease on the part of the 
brain. 

For this purpose, either ipecac, or sulphate of zinc, or a combination 
of the two, should be selected. As a general rule, tartar emetic should 
be avoided.] 

2. Dr. Currie, of Liverpool, began, in 1802, to employ 
the cold affusion as the chief remedial agent in scarlet 
fever. It cools the surface, keeps down fever, and thus 
obviates some of the secondary effects of the poison. 
Dr. Currie was no less sanguine than Dr. Withering, as 
to the value of the improvement which he had intro- 



190 BLOOD-LETTING IN SCARLATINA. 

duced. Sanctioned by my uncle, the late Dr. Gregory 
of Edinburgh, this plan has been amply tried in all parts 
of the world, but it has not realized the expectations of 
its proposer. 

The truth is, that the cold affusion is applicable only 
to a small number of cases. It is adapted for young 
people with high anginose inflammation and a burning 
hot skin, without plethora, without depression of nervous 
energy ; but it is inapplicable to the scarlatina of adults, 
accompanied with coma, phrenitis, or marked debility. 
It is wholly unfit for cases of cynanche maligna. It 
answers its purpose very well for the first day or two, 
but it is often impossible to continue its use. Lastly, it 
seems to increase the disposition to dropsy. Dr. Currie 
proposed to obviate some of these objections by substi- 
tuting tepid sponging for the more formidable affusion, 
but a palliative like this is little fitted to meet the exi- 
gencies of severe cases. Affusion was practised by 
stripping the patient and pouring over his naked body 
four or five gallons of the coldest water, repeating this 
process every two or three hours, until the fever was 
permanently subdued. 

I can recommend this practice to you, as being well 
adapted to the scarlet fever of young persons of san- 
guine temperament, and the early stages of the disorder. 
Cold or tepid sponging with vinegar and water proves 
an useful auxiliary at all periods of the disease. It 
refreshes the patient, relieves headache, and lessens 
restlessness. 

3. Blood-letting, general and topical. Some physi- 
cians discourage all loss of blood in scarlatina, as being 
foreign to the genius of the disease. Others strongly 
advise it. Much will depend upon the character o r a 



GENERAL AND TOPICAL. 191 

symptoms, the period of the disease, the condition of 
the patient ; but I wish to impress upon yon strongly, 
that scarlet fever not only admits of blood-letting, but 
often imperatively requires it, and that on general bleed- 
ing alone the safety of the patient often depends. Let 
me give you a few cases in illustration. 

Miss Ramsay (aetatis 12), in 1832, had scarlet fever. 
On the second day, she became very sleepy. On the 
third day, this sleepiness was fast treading on the con- 
dition of coma. I had her bled in the jugular vein to 
twelve ounces, and all went on well. 

On Thursday, 22d June, 1837, my eldest son, then 
six years old, was seized with rigors and vomiting. On 
the following day, scarlet fever appeared in great in- 
tensity. The boy is of sanguine temperament, and had 
required venesection the preceding year for influenza. 
On the night of Sunday, the 25th, the febrile symptoms 
ran high ; all medicine was rejected by the stomach. 
The long continuance of the vomiting indicated the 
extension of inflammatory action to the mucous mem- 
brane of the stomach, and probably also to the dia- 
phragm and neighboring structures. I bled him to six 
ounces with decided benefit, and feel persuaded that 
without the loss of blood, fever would soon have de- 
stroyed him. 

In 1840, Mrs. Sabine, of Hoxton, took scarlet fever 
during her confinement, and narrowly escaped. Secon- 
dary fever ensued. Languor, failing appetite, and a 
general sense of malaise, continued long. She had 
been sent to Margate for change of air. On her return 
I saw her, and had her immediately bled to twelve 
ounces. Her recovery then went on progressively. 

While I thus advocate the necessity of blood-letting 



192 BLOODLETTING. 

in certain cases, I freely acknowledge that it is inappli- 
cable to others. You would not always do harm by 
the attempt (for it is one thing in scarlet fever to open 
a vein, and another to draw blood), but any such indis- 
criminate use of the remedy would expose you and the 
profession of physic to just reproach. The successful 
treatment of the disease by bleeding in one epidemic, 
at one season, and in one district, does not authorize 
the same procedure in another epidemic, a different 
season, or a different locality. Dr. Willan tells us, that 
in London, in 1785, the usual results of blood-letting 
w r ere, great depression and faintness, the pulse becom- 
ing weak, frequent, and often irregular. Again, in the 
epidemic of 1733, at Edinburgh, we find it stated that 
but few died who were timely blooded. It was then 
remarked, what I have often noticed, that vomiting in 
this disease is only to be checked by venesection. 

The blood drawn in scarlet fever scarcely ever pre- 
sents a firm coagulum. In the majority of cases the 
blood coagulates rapidly into a soft jelly, showing the 
small power in the system, and rendering it probable 
that the urgent symptoms in scarlet fever (such as deli- 
rium and coma) depend more upon congested veins and 
stagnation in the capillaries, than upon arterial action. 
This pathological condition of the circulating system 
was not unknown to the old authors, one of whom 
remarked, that when the superficial vessels are dis- 
tended, there cannot be the same amount of blood in 
the interior as when the skin is cold. We may hence 
learn why fainting so often follows venesection in scar- 
latina, and why we scarcely ever bleed twice. Post- 
mortem examinations confirm this doctrine. Dr. Wells 
records the dissection of a young soldier who died of 



BLOOD-LETTING. 193 

scarlatinal coma, unattended with any considerable 
affection of the throat. No marks of inflammation, or 
even of congestion, were discovered in the brain.* 

Local blood-letting is well adapted to many cases of 
scarlet fever — to cases accompanied with great deter- 
mination of blood to the throat — to cases attended with 
headache, or threatening coma. I applied leeches to 
tbe temples of Mr. Dry, of Tottenham-court-road, 
whose case was detailed in the last lecture. They 
lowered the pulse until it began to flutter alarmingly, 
but the progress of cerebral congestion was checked. 
In tbe management of the several inflammatory sequelae 
of scarlatina (otitis, ophthalmia, and pneumonia), 
leeches and cupping are quite indispensable. 

Leeches generally bleed profusely in scarlatina, from 
the excited state of the cutaneous circulation. Four 
leeches in scarlatina will often do as much as twelve in 
typhus. It becomes occasionally necessary to stop the 
bleeding, which lunar caustic will do effectually. This 
tendency of leech-bites is always to be kept in view, 
but especially in the scarlet fever of young children. 
The child's life might otherwise be sacrificed, and the 
measure itself brought unfairly into disrepute. 

[It may safely be said, that general bleeding in scarlet fever is the 
exception and not the rule, at least in this country. That it may be 
borne in some cases is doubtless true, and that it may be urgently 
called for to relieve congestion of the brain or of other internal organs, 
in occasional cases, is equally true — but it is no less true, that as the 
disease has prevailed of late years in this city, it has not been indicated', 
and has rarely been used, at least with benefit. 

Leeches may more frequently do good, but even these must be used 

* Transactions of a Society for the Improvement of Medical and Chirurgical 
Knowledge, vol. ii. p. 225. 

13 



194 PURGATIVE MEDICINES. 

with great caution in the primary disease. In some of the sequelre, in 
certain cases, their good effect is more decided.] 

4. Purgative Medicines. Dr. Withering, who was 
so devoted to emetics, declared " that the action of 
purgatives was altogether repugnant to the curative 
indications in this disease." On the other hand, Dr. 
Hamilton, of Edinburgh, devoted one chapter of his 
work on Purgative Medicines to the recommendation of 
purgatives. Withering' s prejudices have entirely passed 
away, and purgatives are now largely and most bene- 
ficially used in every stage of scarlatina anginosa, from 
the first onset of fever to the close of the desquamation. 
I know of no objection whatever to their use, and am 
most confident of their great utility. 

The forms of purgative medicine that I would 
recommend to you are calomel and jalap — calomel and 
rhubarb — senna and salts — jalap with cream of tartar — 
senna with cream of tartar — castor oil, — and occasion- 
ally, the combination of calomel, James's powder, and 
extract of colocynth. 

I have often pushed calomel to a great extent both 
in adults and children, — not that I attach importance 
to any specific effect from the mercury, for I never 
saw it do good, except when it purged ; but because, 
in the burning heat of scarlatina, no purgative will act, 
unless aided by the relaxing qualities of calomel. No 
secretion can otherwise be obtained from the vessels 
of the liver and intestinal mucous surface ; and this, I 
need not tell you, is the whole secret and theory of 
purging. You must, of course, be cautious with your 
drastic purgatives, when there is a tendency to syncope. 

[Purgatives are more sparingly used in this country, even in the 



STIMULANTS AND CORDIALS. 195 



anginose form of scarlet fever, as is the case with blood-letting, as 

already remarked, than our author would seem to recommend, and 
some practitioners abstain from them entirely, using only mild laxatives 
or euemata. There are cases of the congestive form, in which the 
prompt effect of an active cathartic is favorable, both by removing 
offending materials from the bowels, and by its revulsive effect ; but it 
is rare that the exhibition, much less the repetition of the active cathar- 
tics enumerated by our author, seems to be called for. At the same 
time, suitable means should be used to keep the bowels sufficiently 
open. 

The use of calomel in this disease originated with Dr. William 
Douglass in the severe epidemic in New England in 1*735 and '36, 
of which he published an account already referred to, page 182. For an 
analysis of his work, and account of the reasons which led him to the 
use of that remedy, see a valuable paper on the ''State of Medicine in 
th- American colonies from their first settlement to the Revolution," by 
John B. Beck, M.D., published in the Transact, of the Med. Soc. of 
the State of New York, Feb., 1850. 

Dr. Jacob Ogden, of Long Island, also used calomel extensively in 
this disease, and with success, about the year 1749. [New York Medi- 
cal Repository, vol. v. p. 97, quoted by Dr. Beck in above-mentioned 
paper, and also in his Infant Therapeutics) 

Calomel has been more or less used in the treatment of scarlet fever 
since that time. Some practitioners continue its use at intervals during 
the whole of the disease, while others give it only at the commencement 
of the attack as a purgative. For this purpose, and when the secretions 
of the stomach and small intestines are disordered, it is often of great 
service. In the formidable laryngeal complication of the disease, its 
exhibition in small doses at short intervals, with appropriate local means, 
should never be neglected.] 



5. Stimulants and cordials are improper (except in 
rare cases) in the early stage, and wholly unfit for the 
inflammatory type of scarlatina. When, either by the 
debility succeeding venesection, or the strong action of 
purgative medicine, or the depressing influence of the 
poison, the pulse flags, the countenance turns pale, and 
the skin cools down, camphor, aether, the citrate of 
ammonia, and similar cordials, with wine, must be 



196 LOCAL TREATMENT OF THE ANGINA. 

given. The only stimulus that can be allowed at all 
times is that of an acid. Direct, therefore, a drachm of 
the diluted hydrochloric acid, with half an ounce of 
syrup of orange peel and eight ounces of water; and 
let the patient take an ounce and a half of such a mix- 
ture frequently. 

The occurrence of diarrhoea demands the employ- 
ment of gentle aromatics and astringents, such as the 
aromatic confection, chalk mixture, and laudanum. 
Arrow root with port wine must be given at the same 
time. In the truly sloughy and gangrenous forms of 
anginose scarlatina, a variety of medicines supposed to 
possess antiseptic properties have been extolled. In 
the West Indies, in 1787, they found an infusion of 
capsicum very serviceable. Dr. Peart recommends very 
strongly the carbonate of ammonia, but Dr. Tweedie's 
large experience does not bear out the encomiums 
which he lavishes on the remedy. One great objection 
to its use is the difficulty of swallowing it — a difficulty, 
indeed, which meets us in every stage of scarlatina, and 
which authors are very little inclined to consider. 

Bark was at one time highly extolled as an antiseptic 
and tonic in scarlatina. It was even given when the 
" heat of the surface was sharp." A broken texture and 
putrid tendency of the blood were then considered valid 
reasons for giving bark. The practice is now seldom 
pursued, except as a last resource, when the throat is 
sloughy, with a small pulse, cold skin, and great nervous 
depression. Wine and brandy, however, are much 
preferable under such circumstances. 

You must not altogether neglect the local treatment 
of the angina. Gargles of rose infusion wash away 
the abundant and vitiated mucus of the throat, give to 



LOCAL TREATMENT OF THE ANGINA. 197 

it a clearer aspect, but do no other good. When there 
is a breach of surface, acids give great pain. You may 
then use with advantage the decoction of bark with 
mel rosae, or Sauvages' once famous gargle, lime-water 
with honey. As children cannot gargle, the nurse must 
be instructed to clear the throat by means of a camel's 
hair pencil dipped in a solution of currant jelly. 

[Local means are often valuable auxiliaries in the treatment of the 
affection of the throat. 

Ice has been used with great advantage in some forms of the disease 
when the throat is much inflamed, and is very grateful to the patient, 
and doubtless has an equalizing effect on the circulation generally, as 
well as a sedative influence on the local heat and swelling. 

Chloride of soda in solution is useful as a gargle when there is 
sloughing, diluted according to the age of the patient, and sweetened 
with honey, about 3j or 3ij of Labaraque's solution to f j water. 

When the tonsils and neighboring parts are in a gangrenous state, 
with but little if any surrounding inflammation, a gargle of sulphate of 
copper is useful, ten to thirty grains to 5 j water, or a solution of sul- 
phate of zinc — or an infusion of capsicum, to which common sale is 
often added with advantage — but in such cases, a solution of nitrate of 
silver, twenty to sixty grains to an ounce of water, is probably the most 
efficient topical remedy, and should never be neglected, if other means 
do not soon succeed. In such cases, yeast often renders essential service 
as a gargle. 

Dr. Watson [Pract. Med) speaks very highly of the chloride of pot- 
ash — 3 ij to be dissolved in I ij hydrochloric acid, previously diluted 
with 5 ij distilled water — to be put into a stoppered bottle, and kept in 
a dark room. Of this solution, 3 ij, with a pint of distilled water, make 
the chlorine mixture. Dose — a tablespoonful or two, according to the 
age of the patient, frequently. 

Others prefer finely pulverized alum in these cases, either applied by 
means of a camel's hair pencil, or blown up the nostrils (as recom- 
mended by Velpeau) by means of a long tube, as two or three quills 
joined together. The application of the strong hydrochloric acid, mixed 
with honey, by means of a pencil, has also been recommended in these 
cases. 

Injections through the nostrils into the posterior fauces either of sim- 



198 MANAGEMENT OF THE SEQUELAE. 

pie warm water, or water medicated with chloride of soda (about 3j to 
5j), either with or without honey, or of a weak solution of nitrate of 
silver, one or two grains to Ij water, will often be of service. 

Emollient poultices, or narcotic fomentations, afford the best external 
applications for the throat.] 

The management of the sequelse of scarlet fever 
next claims jour attention. The cellular inflammation 
of the neck is to be treated by poultices in the first 
instance. As soon as possible, free incisions must be 
made through the skin, to allow of the escape of the 
sloughs, and of that imperfect pus which is all that the 
weakened state of the system permits to be formed. 
The strength to be supported, meantime, with beef-tea 
and wine. 

In that state of general and vascular debility which 
I have described as occasionally occurring as a sequence 
of scarlet fever, the tongue being clean, and the heart 
disposed to syncope, cordial draughts containing 
compound spirit of ammonia with camphor julep 
and tincture of lavender must be freely administered. 
Nourishment, too, must be frequently given with port 
wine. 

The dropsy which succeeds scarlatina deserves all 
your care and consideration. Dr. Wells was, I believe, 
the first to throw off the pathological trammels which 
connected this symptom with debility of the capillaries. 
He saw in it an inflammatory affection ; he noticed its 
coincidence with a white tongue and a sharp pulse, 
and he knew the benefit of an antiphlogistic treatment. 
This doctrine is that now generally admitted. We 
consider the dropsy succeeding scarlatina as depending 
on arterial excitement, either general or local, which 
must be subdued, by mild means if possible, but failing 



MANAGEMENT OF THE DROPSY. 199 

them (or in the event of great urgency, even in the first 
instance), by blood-letting. 

Dropsy seldom occurs early in the secondary fever of 
scarlatina. It is almost always preceded by symptoms 
which will warn you of its approach, when your eyes 
are opened to the pathology of exanthematic sequelae. 
In the larger proportion of cases, you will succeed in 
relieving the dropsy effectually. Plenck, however, a 
celebrated physician of Vienna in the last century, 
who wrote on eruptive fevers (1762), held that the 
danger was even greater from the dropsy than the fever 
itself. 

I cannot doubt but that a large proportion of cases 
of scarlatinal dropsy arise from the neglect of measures 
which ought to have been adopted in an earlier stage 
of the disease. If a certain amount of blood-letting, a 
certain number of doses of calomel and jalap, a certain 
amount of rest and abstinence had been indicated, but 
neglected or withheld, then, when dropsy occurs, the 
deficiency must be made up. The same things must 
be done late, which ought to have been done early. 
In all cases, it is your duty to watch carefully the 
decline of scarlet fever. If the pulse, tongue, and secre- 
tions be not satisfactory, exhibit daily, or on alternate 
days, a purgative draught, containing infusion of senna, 
cream of tartar, and tincture of jalap, so as to insure 
two motions ; direct, at the same time, a diuretic julep, 
containing acetate of potash, tincture of digitalis, and 
the spirit, setheris nitrici, or some equivalent promoter 
of renal activity, in mint water. If these measures do 
not meet the exigencies of the case, if the character of 
the urine, and of the pulse and tongue, indicate increas- 
ing or unabated disorder, take ten or twelve ounces of 



200 MANAGEMENT OF THE DROPSY. 

blood from the arm. Do not wait for the appearance 
of dropsical swellings Jo adopt this proceeding, for by 
such delay farther mischief will ensue. Coagulable 
lymph will be effused on some of the great serous sur- 
faces, or in the interior of the heart. I need not say 
how immeasurably this would add to the seventy of the 
dropsy and the danger of the patient. 

Tonics are not to be entirely thrown aside in the 
management of scarlatinal dropsy. You will meet with 
cases that give countenance to the doctrine that the 
exhalant vessels want tone, that blood is detained in 
the cutaneous capillaries for want of sufficient energy to 
restore it back to the heart. Such cases will necessa- 
rily carry with them other evidences of this condition 
of the system, called by pathologists leucophlegmasia, or 
white inflammation. You will find the countenance 
sallow, the pulse feeble, the tongue clean (perhaps mor- 
bidly red), and the urine, though scanty, yet pale. 
Under such circumstances, you would be justified in 
giving, and expecting benefit from, stimulants, in com- 
bination with diuretics. The infusion of cascarilla, 
mixed with tincture of capsicum, compound spirits of 
juniper, the spirit of nitric aether, a few drops of tincture 
of digitalis, and some syrup of ginger, will supply you 
with an old-fashioned, but not the less serviceable 
combination. 

The compound squill pill, with a due proportion of 
pilula hydrargyri, may be given night and morning, so 
as to insure the activity of the kidney. 

M easures such as these will sufficiently relieve a very 
large proportion of the cases of scarlatinal dropsy which 
you will meet with, but some will prove rebellious to 
all your care, probably from the serious injury done to 



TREATMENT OF SCARLATINAL CONVULSIONS. 201 

the longs, liver, or heart, in the first days of the disor- 
der. My earnest advice to yon, therefore, is to try and 
pn vent the secondary dropsy rather than to display 
your skill by curing it when it has arisen. 

[For further remarks on the treatment of dropsy following scarlet 
fever, see Appendix I.] 

Convulsions occurring during the secondary fever of 
scarlatina demand the loss of blood either from the arm 
or by leeches, according to the age and strength of the 
patient, with active purgatives containing calomel, and 
the application of cold spirituous lotions to the head 
and prsecordial region. 

[Dr. Marshall Hall relates a case of acute anasarca and convulsions in 
a boy, twelve years old, cured by venesection, followed by leeches, 
with purgatives, cold to the head, pediluvia, etc., and says he considers 
that, in such cases, the remedy is blood-letting, until relief and security 
are obtained. (Amer. Jour. Med. Sci., Feb., 1840, p. 450, quoted from 
London Lancet.) 

At a meeting of the Royal Med. Chir. Soc. (London) in Feb., 1847, 
Dr. Rogers remarked that he had seen two cases of scarlatinal convul- 
sions, which came on after the twenty-first day of the disease — both 
patients having suffered from dropsy with albuminuria. In one case, 
he used dry cupping over the loins ; in the other, at the nape of the 
neck — both recovered. 

Without entering further into the particulars of the treatment of 
scarlet fever, either generally or locally, we will add a few propositions 
which we think worthy of remembrance, and the truth of which will 
probably not be questioned : 

1. It is a self-limited disease, and nature is often entirely competent 
to conduct our patient safely through it. 

2. It presents every variety as to type and mode of attack, and every 
degree as to severity, and hence we must prescribe for the symptoms, 
and not for the name of the disease. 

3. Ataxic symptoms and local determinations are those which most 
frequently require the interference of art. 

4. The poison of the miasm is of a most depressing nature, and 



202 GENERAL PRINCIPLES OF TREATMENT. 

hence great caution is required in the use of means which tend to 
exhaust the vital powers. 

5. The sequela of the disease are often much more formidable than 
the disease itself, and must always be carefully watched for and guarded 
against, depending, as they often do, upon the management of the case 
in its earlier stages. 

6. The nature of the prevailing epidemic should always be carefully 
studied, both in the management of our own cases at any particular 
time, and in judging of the treatment of recorded cases ; for the history 
of different epidemics, both in this country and abroad, proves conclu- 
sively that the most opposite means have been equally successful at 
different times, and in different places. 



LECTURE IX. 

ERYSIPELAS. 

Etymology of erysipelas and St. Anthony's fire. Ancient opinions con- 
cerning the sources of erysipelas. Gradual changes in the views enter- 
tained on the causes of erysipelas. Opinions of Dr. Wells. Contagious- 
ness of erysipelas. Its miasmatic origin. Its relation to puerperal 
peritonitis and hospital gangrene. Views of Dr. Rollo. Of hospital 
miasm. Other sources of erysipelas. Connexion of erysipelas with 
breach of surface. Inoculation of erysipelas. Incubation. Phenomena 
of erysipelas. Of the erysipelas phlegmonodes and gangrenosum. 
Extension of erysipelas from the skin to the brain, and other internal 
organs. Statistics of erysipelas. Treatment. Efficacy of blood-letting, 
purgatives, and stimulants. Local treatment of erysipelas. 

Erysipelas, called also the rose, ignis sacer, and St 
Anthony's fire, is an exanthema, and therefore properly 
falls to be discussed in this division of the course ; but 
we shall find its pathology to be in many points differ- 
ent from that of the three diseases already treated of. 
It is, in fact, the link which connects the purely zymotic 
exanthemata with those diseases of the human body 
which originate from internal causes, and are uncon- 
nected with specific miasm. Erysipelas is a disease of 
which the . pathological bearings, long as it has been 
known, are only now beginning to be well understood. 
It is a disease which, from its occasional severity, as 
well as on account of its frequency, merits your best 
attention. 

Little need be said regarding the literary history of 
erysipelas. It was well known to the Greeks and 
Romans, and we retain the name which Hippocrates 
and the Greek physicians originally gave it. Two 



204 ETYMOLOGY OF ERYSIPELAS. 

derivations of the word erysipelas are proposed, both 
supported by high classical authority ; some derive it 
from the two Greek words spufyoj, red, and ^sXXos, livid 
— livid redness. The German lexicographers sanction 
this derivation. Almost all the English authorities 
(including Donnegan) derive the word from epuw, to draw 
forth, and *zko.g, near ; expressive, it is said, of the ten- 
dency of the disorder to spread or extend itself to 
neighboring parts, in contradistinction to those forms 
of inflammation called by the Greeks apostatic («<™ and 
KrT^fxi) and metastatic, from their more fixed nature. I 
give you your choice of the two derivations, premising 
that I prefer the first. 

The term St. Anthony's fire was first applied to this 
disease in the dark ages of literature, when all the little 
physic that was known was monopolized by monks and 
ecclesiastics, who, in cases of difficulty, naturally sought 
aid in prayer and invocation. Diseases came thus to be 
consigned to one or other of the many saints in the 
Romish calendar. The intercession of St. Nicasius 
was implored in small pox. St. Vitus's shrine was 
sought by those who labored under chorea. Erysipelas 
had for its patron St. Anthony. The circumstances 
which led to this selection are not unknown. In 1087, 
a pestilential erysipelas, or sacred fire, ravaged the inte- 
rior of France, and especially the district of Dauphine. 
Now it so happened, that two years previous to this 
epidemic, the bones and relics of St. Anthony had been 
brought from Constantinople by the pious care of 
Joselin, a nobleman of that country, and deposited in 
the church of a Benedictine priory, in the neighborhood 
of Vienne. Numbers of pilgrims flocked thither, and 
many miraculous cures were there performed. This 



ANCIENT OPINIONS OF ERYSIPELAS. 205 

success fixed St. Anthony in the perpetual patronage 
of erysipelas. 

We may gather something from the simple fact that 
erysipelas was known to and well described by Hippo- 
crates. It shows us that physicians who could so dis- 
tinguish erysipelas would not have failed to describe 
with equal accuracy, and to name with equal judgment, 
small pox, measles, and scarlet fever, had those diseases 
existed in their days. Their not doing so is proof 
positive that such diseases did not then exist. It show 7 s, 
further, that there must be something very different in 
the great pathological features of erysipelas from those 
of the three greater exanthemata ; else how did it hap- 
pen that erysipelas should have been known to them, 
and not the three others 1 

It will conduce to a clearer understanding of erysipelas, 
if, in treating of it, I reverse the order in which I have 
hitherto investigated the eruptive fevers. I shall here 
first explain to you the pathology of erysipelas. I shall 
attempt to show you in what respects it differs from the 
other exanthemata, under what circumstances it origin- 
ates, and what explanation of its various sources has 
been offered by ancient as well as by modern authors. 
Having thus discussed the subject of erysipelas theoreti- 
cally, we shall be better prepared for the investigation 
of its appearances, its progress, its terminations, its sta- 
tistics, and, lastly, its method of treatment. 

I must begin by informing you, that by the term 
erysipelas we mean an inflammation of the skin, and 
very commonly, also, of the subjacent cellular texture ; 
often preceded, and almost invariably accompanied, by 
fever. Such a disorder originates from various causes. 
Its course and duration are alike variable. So far from 



206 CAUSES OF ERYSIPELAS. 

the constitutional susceptibility (as in the case of the 
three greater exanthemata) being exhausted by one 
attack of erysipelas, the disposition to the disease seems 
often, as life advances, to augment with each successive 
seizure. 

I shall have occasion to notice great diversities of 
opinion among authors upon almost every topic which 
the pathology of erysipelas involves. Nosologists differ 
as to its true situation, whether among the exanthemata 
or the phlegmasia^. There are strange contradictions 
in the statements of authors regarding the mode of its 
propagation, and still wider differences of opinion in 
respect of the best method of treating the disease. 

With regard to nosology, we have outlived that idle 
display of learning which made it an object of impor- 
tance to what class or order any particular disease was 
to be assigned. We consider it here as an exanthema, 
following in this respect the footsteps of Dr. Cullen ; 
but I beg you clearly to understand, that very good 
reasons might be advanced why it should be transferred 
to the phlegmasia?. The matter, however, is not worth 
wasting time about. 

With respect to the causes of erysipelas, however, 
and the manner in which it spreads, the diversities of 
opinion are of infinitely more importance ; and these 
must now be carefully investigated. 

In ancient times, by Hippocrates, and the followers 
of the Hippocratic or humoral pathology, erysipelas was 
held to be a disease originating from some intestine 
commotion of the humors, which threw off, or elimi- 
nated, the peccant matter by means of the skin. This 
doctrine continued, with very slight change of phrase- 
ology, to be generally received by pathologists until a 



OPINION OF DR. WELLS. 207 

comparatively recent period. Dr. Cullen says, " I con- 
sider the erysipelas to depend on a matter generated 
within the body, and which, analogous to the other 
cases of exanthema, is, in consequence of fever, thrown 
out upon the surface of the body." He admits a spe- 
cies of erysipelas (or rather, erythema) arising from an 
external cause, capable of throwing off contagious ema- 
nations, but he makes no mention of any morbid poison 
or miasm primarily giving rise to it. His words are — 
" This disease is not commonly contagious, but as it 
may arise from an acrid matter externally applied, so it 
is possible that the disease may sometimes be commu- 
nicated from one person to another." 

The modern notions of the nature, and sources, and 
pathological relations of erysipelas, have made con- 
siderable advances since the days of Cullen (now more 
than half a century ago). I know no author who has 
laid them down fully, but Dr. Williams, in his valuable 
work " On the Morbid Poisons." 

The first inroad upon the old notions concerning 
erysipelas was made by Dr. Wells, formerly physician of 
this hospital, who, in 1798, published some statements 
showing the contagiousness of erysipelas. These facts, 
and the opinion founded on them, were long neglected ; 
but of late years they have been forced upon the atten- 
tion of pathologists, by the undeniable evidence of the 
frequent spreading of erysipelas in hospitals, and the 
difficulty of explaining that circumstance on any other 
principle than that of the generation of erysipelas by a 
morbid poison, or miasm. 

I propose, first, to state to you the facts which prove 
erysipelas to be an epidemic malady, and which, satis- 
factorily to my mind, show that its most important 



208 MIASMATIC ORIGIN OF ERYSIPELAS. 

source is miasmatic. I shall then tell you on what 
grounds we further maintain that this miasm, when 
formed, is capahle of propagating itself by contagious 
emanations. Lastly, it will be my duty to explain to 
you how erysipelas originates occasionally from causes 
not of a specific nature, some of which are internal, 
others external to the human frame. 

Sauvages, in his " Nosologia Methodica," published 
soon after his death (which took place in 1767), admits 
an erysipelas contagiosum, but on what turns out to be 
most doubtful authority, for the epidemic referred to by 
him in support of that opinion (that of Toulouse, in 
1715) was scarlatina, not erysipelas : in fact, we cannot 
detect any trace of the doctrine of miasmatic erysipelas 
prior to the year 1760. In the summer of that year, a 
person laboring under erysipelas of the face was brought 
into this very hospital, where he died. Another patient, 
having a different disease, was put into the same bed 
before it was duly purified. This patient was shortly 
after seized with erysipelas of the face. Several other 
persons in the hospital were then attacked, among whom 
was an upper nurse, or sister, and she died. A rumor 
hence arose that the plague had got into the hospital; 
and so widely did this opinion spread, that an adver- 
tisement was inserted in the newspapers of the day, 
contradicting the rumor. This, you will observe, is an 
instance of erysipelas brought into a hospital, and there 
propagating itself. I am not able to tell you who first 
noticed the fact that erysipelas will commence in a 
hospital, without any suspicion of importation. Dr. 
Baillie informs us that during the years 1795 and 1796, 
erysipelas < f the face was much more frequent at St. 



MIASMATIC ORIGIN OF ERYSIPELAS. 209 

George's Hospital than he had ever before known it to 
be. Many persons, he says, were attacked by this dis- 
ease after they came to the hospital ; and as the cases 
in a particular ward were more numerous than in any 
other, Dr. Baillie was led to suspect that the disorder 
was contagious. He is silent, however, on the subject 
of origin ; and we are unable to say whether this erysi- 
pelas was origiually bred in the hospital, or imported, 
and afterwards propagated by contagion. 

M. Calmiel, writing in 1828, says, " there are years 
when in the hospitals for the insane in Paris, erysipelas 
is almost indefinitely multiplied ; so that it is necessary 
to suspend all treatment by counter-irritants (setons, 
moxas, and blisters), because they are almost certainly 
followed by erysipelas. Even the opening of a vein, or 
the application of leeches, is followed by a like result. 
We may be quite sure that these cases must have origin- 
ated within the hospital, for it would be unreasonable 
to suppose that an insane patient actually suffering 
under erysipelas would be admitted. 

M. Velpeau, writing in 1831, describes the epidemic 
prevalence of erysipelas in the Hopital de la Pitie, 
where he notices, that both in the medical and surgical 
wards the application of leeches, a trivial operation, or 
even an accidental puncture, brought on this inflamma- 
tion with all its consequences. Blache and Choinel 
also mention the epidemic prevalence of erysipelas, and 
instance the autumn of 1818, a year of excessive heat 
and long drought. Of all the Paris hospitals, the Hotel 
Dieu is that which has suffered most frequently and 
most severely by this terrible scourge of hospital esta- 
blishments. 

There is not, I believe, a single hospital in London, 

14 



210 CONNEXION OF ERYSIPELAS 

which has not, at times, been afflicted in like manner. 
At St. George's I have several times seen erysipelas so 
prevalent that operations were postponed for fear of the 
patient being subsequently attacked by it. 

A connexion of more than twenty years with the 
Small Pox Hospital has given me abundant opportuni- 
ties, not only of confirming the truth of these positions, 
but of showing that we may carry our views much 
further. I feel persuaded, first, that erysipelas may 
commence in an hospital without the suspicion of im- 
portation. 2. That being so generated, from bed to 
bed, it may spread by contagion. 3. That the miasm 
generating erysipelas is identical with that which in 
lying-in hospitals generates puerperal peritonitis, which 
in foundling hospitals and workhouse nurseries gives rise 
to pudendal gangrene and umbilical ulceration — which 
in army hospitals generates hospital gangrene — which 
in hospitals differently circumstanced is found to occa- 
sion a malignant form of cynanche, both mucous and 
cellular, with otitis, glossitis, an asthenic form of laryn- 
gitis, and sometimes the most aggravated type of typhus 
gravior. 

The origin of scurvy in crowded and ill regulated 
ships is obviously a branch of the same general doctrine. 
A destructive miasm is there generated which is far 
more injurious to the human frame than the use of salt 
provisions. Whatever be the exact nature (or essence) 
of the miasm which thus generates erysipelas, peritoni- 
tis, gangrenous ulceration, or scorbutic blotches, it is 
something depressing to the vital power. 

The dependence of erysipelas on a miasm sui generis 
is no new doctrine. It has been stated over and over 
again, by individual writers, but it has never, I think, 



WITH OCHLETIC MIASM. 211 

been urged by systematic authors with the importance 
which it merits; nor has the doctrine been received as 
one of the avowed axioms of pathology. Dr. Rollo, in 
a treatise entitled " 4- Short Account of a Morbid Poison 
acting on Sores," and published very early in this cen- 
tury, distinctly announces the principle, and illustrates 
the intimate connexion between erysipelas and hospital 
gangrene. 

[We would remind our readers that our author has given the name 
of ochletic miasm (from o^Xo^, a crowd) to the peculiar miasm generated 
in hospitals, crowded apartments, &c., &c, and the generic title of 
Ochlesis, to the several forms of internal and external disease thence 
arising. (See Medical Times (London), Mar. 31, 1849.)] 

The circumstances which lead to the development 
of ochletic miasm have never been investigated with all 
the accuracy which is desirable, and of which the sub- 
ject is certainly susceptible. The first in importance is 
undoubtedly overcrowding of the wards of an hospital. 
When the French academicians (I think it was early 
in the French Revolution) were laboring diligently to 
reform the abuses in the Hotel Dieu, some of them were 
at the pains to calculate in how many hours, supposing 
the ward to have been hermetically sealed, all the patients 
in it must necessarily have died, presuming that each 
adult requires for his support a gallon of air per minute. 
The time was wonderfully short. 

2. But it is not numbers alone which are to be con- 
sidered. A ward might safely hold fifty cases of simple 
fracture, which would not with safety contain twenty 
cases of compound fracture. Something, therefore, 
depends on the nature of the disorder. All disorders 
which throw out diseased secretions are more apt to 
taint and vitiate the air, than those where no such 



212 ochletic miasm: 

secreting process goes forward. It is on this account 
that the wards of the Small Pox Hospital are so pecu- 
liarly liable to generate ochletic miasm. 

3. Another element of great importance in determin- 
ing the sources of ochletic miasm is the degree of 
attention bestowed on cleanliness. If the bed linen, 
mattresses, palliasses, sheets, and blankets, be frequently 
changed, the floors well cleaned, and the walls fre- 
quently whitewashed ; if the nurses be careful to carry 
away all foul secretions, and to purify the patient's body 
by abundance of soap and water ; in short, if the inter- 
nal regulations of the hospital be good, miasm would, I 
suppose, be rarely engendered, even though the ward 
were crowded. 

In the summer of 1844, 1 saw at the Vache in Buck- 
inghamshire, a nursery of 500 young pheasants brought 
up by hens. The attendant informed me that the great 
secret of securing the health of the young brood is to 
change the sleeping ground daily. If the locality of 
the encamped aviary was not thus changed, a disease 
speedily developed itself which was extensively fatal. 

4. A fourth element must enter into the calculation, 
and that is, a good supply of fresh air. This by some 
is considered all in all ; but it is not so, and all the ven- 
tilation in the world, conducted on the most scientific 
principles, and superintended by Dr. Reid himself, would 
fail in preventing ochletic miasm, if feather beds and 
bolsters, soaked in unhealthy discharges, are permitted 
to remain in the ward. 

5. Dr. Rollo has advanced a step further in the 
analysis of the sources of ochletic miasm, and maintains 
that the disposition to erysipelas and its correlative dis- 
eases (puerperal peritonitis and hospital gangrene) 



OPINIONS RESPECTING IT. 213 

depends partly on a peculiar but hitherto undetected 
condition of the atmosphere. He is led to this opinion 
by observing that erysipelas sometimes shows itself in 
the airiest, least crowded, and best regulated hospitals. 
Without stopping to inquire how much is due to this 
circumstance, we are fully warranted in saying that the 
state of the atmosphere must not be lost sight of in such 
an investigation. We know, on the authority of Dr. 
Lind, that in Batavia and other localities notorious for 
malaria, hospital gangrene and erysipelas, and every 
sort of associated disorder, prevail with intensity at cer- 
tain seasons. 

Assuming it as proved, that erysipelas is liable, from 
one or more of the five causes now detailed (viz. accu- 
mulation of persons, character of the discharges, want of 
cleanliness, want of ventilation, constitution of the atmo- 
sphere), to spread epidemically, it is still to be shown 
that this disease throws off contagious emanations, 
which can, per se, independent of any such influences, 
propagate the like complaint. 

Dr. Wells has met this question very fairly by detail- 
ing a variety of cases where erysipelas spread by conta- 
gion in private houses, and under circumstances calcu- 
lated to exclude all agency save that of simple contagion. 
I will state to you a few of these cases ; first, because 
the doctrine of contagion in erysipelas is distrusted on 
the continent, and by many, too, in this country ; and 
secondly, because it is important either to establish or 
to negative the statement. 

On the 8th of August, 1796, Dr. Wells attended, in 
Vine street, Clerkenwell, an elderly man, named Skel- 
ton, with erysipelas of the face, who died. A few days 
after his decease, his wife took it, and died also. 



214 OTHER SOURCES 

Shortly after that, Skelton's nephew, a young man, who 
had visited his uncle during his illness, took erysipelas, 
and survived only a few days. On the 19th February, 
Dr. Wells was called to attend Mrs. Dyke, the landlady 
of the house in which Skelton and his wife had died, 
and she also was found to be laboring under erysipelas. 
She had attended them in their sickness ; and after their 
death, furniture from their room had been removed to 
her apartment. 

Dr. Pitcairn (a most acute physician) attended, in 
February, 1797, a lady with child-bed fever, who had 
erysipelatous inflammation in her skin. Her new-born 
babe had erysipelas of the pudendum, and both mother 
and child died after a few days' illness. Eight days 
after the death of the child, the lady's mother and a 
servant maid, both of whom had attended the child in 
its illness, were attacked with erysipelas faciei, from 
which both recovered. 

Many similar cases are recorded. It is not meant 
to insinuate that such are common. In by far the 
larger proportion of cases where erysipelas invades pri- 
vate families, no such result follows, — no member of 
the family, no nurse sickens, but the possibility of such 
an occurrence is to my mind satisfactorily proved. 

[Similar instances of the spread of erysipelas in private houses have 
occurred under my own observation, and doubtless also to others ; but 
the question may properly be asked, whether the small proportion of 
cases in which such communication takes place, does not afford fair 
ground for the supposition that some other cause, as, for instance, epi- 
demic influence, or vitiated excretions from the patient first attacked in 
a small apartment, in conjunction with still other causes, may not have 
been the occasion of such propagation in these cases, instead of contagion, 
a term, the use of which ought perhaps to be restricted to specific commu- 
nicable diseases.] 



OF ERYSIPELAS. 215 

It remains, before I bring this branch of the subject to 
a conclusion, that I inform you what are the circum- 
stances, independent of contagion and miasm, which are 
believed by pathologists to induce erysipelas. Here 
another wide field of inquiry opens before us. 

I told you that the miasms of small pox, measles, and 
scarlet fever, operate on the human body without pre- 
disposing causes. A child in the most perfect health is 
even more susceptible of these diseases than one out of 
health. That is not the law with erysipelas. It has 
long been known that certain conditions of the body 
favor very much the development of erysipelas. 

1. Weakness of the body, whether the result of ener- 
vating employments, of prior ailment, or of bad food, 
contributes to bring the frame under the dominion of 
erysipelas. Hence it is that erysipelas is so frequent a 
consequence of typhus fever, of small pox, and of all 
febrile diseases which seriously reduce the vis vitse. 

2. Erysipelas is a frequent complaint in military hos- 
pitals. It is met with in soldiers of full habit of body, 
as well as in those of intemperate habits of life. It has 
therefore for its predisposing causes plethora and an 
inflammatory diathesis. Medical men who have only 
seen erysipelas in the wards of a London hospital, have 
little idea of the phenomena which it presents, and of 
the treatment which is required, when it invades the 
plethoric soldier in the prime of life, eating abundantly 
of animal food, drinking to excess of bad wine, and 
exposed at night, without exercise, to the chilling damps 
of an unwholesome atmosphere. Some of the most 
formidable cases of erysipelas initiate in these circum- 
stances. 

3. The third source of erysipelas, independent of spe- 



216 SOURCES OF ERYSIPELAS. 

cific miasm, is original delicacy of structure and consti- 
tution. Women, formed of more delicate materials, 
and often endowed with less of constitutional power 
than men, are thereby rendered more liable to erysipelas. 
Some women, of weakly habit, and very delicate texture 
of skin, hardly pass a year without an attack. This 
delicacy of skin is hereditary, being transmitted, like the 
lineaments of the face or the color of the hair, from 
mother to daughter. Hence it is that erysipelas, like 
gout and gravel, is hereditary in certain families. In 
persons thus predisposed, erysipelas may be brought out 
by cold, by heat, by any violent exertion, by strong 
emotion of mind, by a deranged state of the liver and 
digestive organs, by atmospheric changes, especially the 
setting in of the winter season. 

[Of 373 cases of this disease which occurred at the hospital of 
Stuttgart from 1828 to 1838, 117 were males and 256 females. Frank 
gives the proportion of females to males as high as 4 to 1, and Phillips, 
of London, in the proportion of 3 to 2. 

In 630 cases distributed by the Bureau central, to the various hospi- 
tals of Paris during the years 1830 and 1831, there were 326 females- 
In 43 cases observed by Louis, 25 were women, as were also 13 out of 
20 patients with it received into Chomel's clinical wards at La Charite 
Hospital.] 

4. The last of the common causes of erysipelas is 
breach of surface. In the very worst wards of an hospi- 
tal, in the most unfavorable weather, in a habit of body 
originally most prone to erysipelas, it often happens that 
the disease is not developed until the surface of the body 
be abraded or wounded. All sorts of wounds, whether 
made by leeches, lancets, the knife of the surgeon, the 
sword of the enemy, or the forceps of the dentist, all 
sores and ulcers, are at times followed by erysipelas. 
You may naturally inquire, why X The reason proba- 



INOCULATION OF ERYSIPELAS. 217 

blv is, that erysipelas is the product of a morbid poison, 
and we know that all morbid poisons are more easily 
received by a wounded surface than by a whole skin. 
This doctrine applies to small pox, cow pox, measles, 
aud hydrophobia. The disease is, in fact, thus intro- 
duced by a kind of inoculation. All breaches of sur- 
face, then, favor the development of erysipelas. It is 
there, where the action begins, and from which, as from 
a centre, it is diffused over more or less of the superfi- 
cies. Let me further remind you that erysipelas may 
be excited artificially, by a burn, a scald, a mustard 
poultice, ammonia, or cantharides. The inflammation 
excited by a blister is erysipelatous. 

Dr. Willan was of opinion that erysipelas could be 
propagated by inoculation. He tells us that the fluid 
secretion of the vesicles will occasion a red, painful, 
and diffuse inflammation of the skin, in all respects like 
that of true erysipelas. These experiments ought never 
to have been made, and do not appear to have ever 
been repeated. The facts, therefore, are open to doubt. 
I have heard of a case where vaccine matter taken from 
the arm of a child laboring under erysipelas com- 
municated both diseases. But it did not fall under my 
own notice, and possibly may have been misrepre- 
sented. 

From this sketch of the pathology of erysipelas you 
will see how intricate the subject is, and how widely it 
behoves you to extend your views, if you would fully 
inform yourselves of its sources. 

The latent or incubative period of the erysipelatous 
miasm is very short, certainly not exceeding one week. 
It is capable, like other miasms, of attaching itself to 
fomites, and, so far as I have observed, is more difficultly 



218 PHENOMENA OF ERYSIPELAS. 

banished from such fomites than any other known con- 
tagion. 

[In an epidemic which prevailed at Petersburgh (Virginia), during 
the winter and spring of 1844-45, according to the observations of Dr. 
Harrison, in Sussex county, the period of incubation in 14 cases was, in 
every case, seven days. (Peebles on Epidemic Erysipelas, Amer. Jour. 
Med. Sci, Jan. 1846.)] 

Erysipelas sometimes begins without any very per- 
ceptible marks of fever. In general, however, when 
this happens, the succeeding disorder proves very mild, 
and some nosologists have refused to apply the term 
" erysipelas" to it. They would fain restrict that desig- 
nation to cases of a more noble character, such as are 
preceded by fever, and accompanied in their progress 
by well marked constitutional disturbance. To the 
milder forms of rose-rash they appropriate the term ery- 
thema. This nosological refinement is wholly inappli- 
cable in practice. You will find that in nature a gra- 
dation can be traced from the mildest form of local 
erythema without fever to the most aggravated case of 
constitutional, epidemic, and perhaps fatal erysipelas. 
No precise point can be fixed upon as the boundary of 
erythema and erysipelas. 

Keeping this principle in view, I will tell you what 
are the kind of symptoms present when a person is 
breeding afebris erysipelatosa, whether within the walls 
of an hospital or in a private house — whether succeed- 
ing a wound, or arising from some obscure internal 
cause — whether ultimately to develop itself on the face, 
or on the extremities. The patient has a rigor, fol- 
lowed by heat of skin. His tongue becomes white ; he 
feels languid and incapable of the exertion, mental or 
bodily, which previously was easy to him. Very often 



PHENOMENA OF ERYSIPELAS. 219 

there is sickness at stomach, and vomiting. I know no 
symptom more common than this. You will remember 
how it accompanies the onset of small pox. I have 
seen the same, equally severe and long continued, daring 
the incubative period of erysipelas. Other symptoms 
are also present, such as thirst, headache, disturbed 
dreams, or perhaps complete sleeplessness, confusion of 
thought — but I know nothing which can be called 
characteristic of approaching erysipelas, as contradistin- 
guished from any other kind of eruptive ailment. The 
circumstances in which the patient is placed contribute 
materially to guide you to a right conclusion as to the 
nature of the malady which is breeding. Thus, when 
such symptoms occur, at the Small Pox Hospital, sud- 
denly, to a man recovering from small pox, we know 
that erysipelas is going to show itself, and we are on 
the watch for it. So, in like manner, at the Fever 
Hospital, though there it has happened that small pox 
has followed, and not erysipelas. The pulse is pecu- 
liarly quick and sharp during the onset of this disease. 

[M. Grisolle mentions as a premonitory symptom occurring in two 
thirds of the cases of erysipelas, a painful engorgement of the lymphatic 
glands which receive the vessels coming from the part about to be 
attacked, although the skin presents as yet no appreciable change in any 
respect. This engorgement of the glands precedes the development of 
the erysipelas 1, 2, or 3 days, and sometimes even precedes the redness 
7, 8, or 9 days. M. Chomel has particularly directed attention to the 
same symptom. (Traite de Pathol. Interne.) 

It ought to be borne in mind, however, that, in quite a number of 
cases, the disease, even in a severe form, may come on without premoni- 
tory symptoms, the local affection being the first manifestation of it, 
especially in secondary cases, as in typhus fever.] 

Mr. Arnott is of opinion that an inflammatory state 
of the fauces accompanies in every case the initiatory 



220 PHENOMENA OF ERYSIPELAS. 

fever of idiopathic erysipelas. I have noticed the same 
circumstance when the disorder has originated from 
ochletic miasm. The intensity of the initiatory fever 
of erysipelas is sometimes excessive. Some years ago, 
a patient at the Small Pox Hospital died during the 
incubation of a fever, which I had every reason to 
believe was erysipelatous. 

[In the epidemic of erysipelas in Petersburgh, previously referred to, 
Dr. Peebles says that the affection of the throat was the " only symptom 
invariably present, — in the mildest forms of the disease, the chief symp- 
tom complained of; in the severe and malignant form, one of the most 
formidable complications." He says, a diagnostic mark of the throat 
affection was, the uvula singularly relaxed and elongated, and always 
having suspended from its extremity a pellicle of viscid limpid mucus, 
sometimes resting on the tongue, which could be with difficulty removed 
by the patient or by a sponge. (Amer. Jour. Med. Sci., Jan. 1846.) 

Dr. J. A. Allen, in his account of an epidemic of this disease which 
prevailed in Middlebury (Vermont), in the winter of 1841-42, says that 
the throat was uniformly found inflamed. (Boston Med. and Surg. 
Journ., 1844.)] 

After a period, varying from twenty-four to sixty 
hours, a redness appears either on the face or on the 
leg, or sometimes (though much more rarely) on the 
trunk. The redness is soon succeeded by swelling, 
and a sense of heat in the part. The redness and 
swelling extend. When the eruption attacks the head, 
the side of the nose is generally the part first affected, 
but sometimes the temple or ear. The swelling soon 
reaches the eyelids, w T hich assume a peculiarly puffy or 
oedematous aspect, and often the eyes are for a time 
closed. Should the disorder prove severe, the face may 
swell to such an extent as to present a truly hideous 
spectacle, all trace of the natural features and expression 
of countenance being entirely gone. The extent of 



PHENOMENA OF ERYSIPELAS. 221 

surface occupied by redness is extremely varied. I 
have seen erysipelas cease when one side only of , the 
face had become affected. I have seen it extend from 
the scalp to the neck, from the neck to the breast, and 
there suddenly stop. At other times, it descends to the 
extremities, and ceases not until every portion of the 
skin has been successively attacked. Such cases, how- 
ever, are very rare, for in general before that can take 
place, some internal organ has become affected, the 
constitution has given way, and the patient been carried* 
off, either by coma, vomiting, or diarrhcea. 

[Erysipelas sometimes attacks the scalp without extending to the 
face, but this form of the disease is so rare, that M. Chomel has not 
seen more than three or four cases of it. A case is recorded by M. 
Grisolle {Brit, and For. Med. Rev., April, 1S48, p. 54V, taken from 
V Union Medicate, No. 14), in which the earliest symptoms were a 
stiffness of the neck and enlargement of the cervical glands, the latter 
being a very common, though not a constant precursor of the disease. 
The symptoms of this form are often very obscure. Pain and oedema 
of the scalp are, however, usually present, and redness may be seen on 
close examination. Vesicles never form on that part, but numerous 
small abscesses sometimes appear at the close of the disease. Delirium 
is one of the most unfavorable symptoms, but is only sympathetic, and 
not owing to inflammation of the brain or its membranes, as proved by 
the autopsies made by MM. Chomel, Louis, and Grisolle.] 

The redness of erysipelas is easily distinguished. It 
fades under the finger. It is bounded by a distinct 
margin. The skin occupied by it is soft and inelastic. 
It is accompanied by a sense of heat, or scalding. 
There is no throbbing complained of, nor any sharp 
lancinating pain, as. in phlegmon. 

[This distinctly marked, slightly elevated margin is characteristic of 
ery-ipelas, and is always produced at the limit of its extension every 
time there is a tendency of the disease to extend itself. Chomel 
remarks that, by means of this conterminous swelling, the periods of 



222 ERYSIPELAS GANGRENOSUM. 

shifting may be recognised, and by its absence, the period of definite 
limitation ; and that this double character is of importance, especially 
when we wish to determine the value of remedies said to check the 
progress of the erratic form.] 

Very mild cases of erysipelas sometimes subside with- 
out any further appearances than those now described ; 
but in all cases of even ordinary intensity, the cuticle 
becomes (in a period varying from twelve to thirty-six 
hours) elevated into small vesicles, blebs, or blisters — 
precisely like those which form after the application of 
a plaster of cantharides, or which we see after a burn or 
scald. These blebs or vesicles contain a thin ichor or 
serum, sometimes perfectly transparent, sometimes yel- 
lowish, sometimes livid, and occasionally mixed with 
blood. They soon burst and discharge their contents, 
while the subjacent surface of the corion becomes of a 
reddish brown, or perhaps livid color, according to the 
degree of constitutional power present. The cuticle 
over the whole extent of the erysipelatous surface is 
killed, and desquamates, as in scarlatina, in the course 
of the succeeding fortnight. 

I have told you that the cutis vera may assume a livid 
aspect. I may add, that at times erysipelas exhibits 
still more aggravated and even appalling appearances. 
Pure gangrene supervenes, the constitution sympathizes, 
and the patient dies in the course of a week (generally 
about the third or fourth day), with symptoms of 
oppressed brain (coma or convulsion) — or with vomit- 
ing and diarrhoea — or with oppressed breathing and 
excessive restlessness. In these cases, prior to the gan- 
grene, the skin appears hot, tense, and acutely painful. 
The pulse is rapid, almost beyond counting, and the 
expression of countenance betrays the utmost anxiety. 






ERYSIPELAS GANGRENOSUM. 223 

Nowhere is this frightful form of erysipelas gangreno- 
sum more frequently witnessed than in badly-ventilated, 
over-crowded, and ill-regulated foundling hospitals and 
workhouse nurseries. The erysipelas neonatorum, and 
the erysipelas pudendorum ulcer ans, have been described 
by Dr. Garthshore, by Dr. Underwood, by Dr. Percival 
of Manchester, and Mr. Kinder Wood of Oldham. 
Fortunately, we have not many opportunities of seeing 
such things in this country, but on the continent, where 
foundling hospitals are in fashion, the disease, in all its 
malignity, is still occasionally witnessed. It attacks 
children from the period of birth to the second month, 
or even later, and chiefly affects the umbilicus, genitals, 
and groins. 

On dissection of those who have died of this disease, 
Dr. Garthshore was unable to detect any lesion of the 
internal viscera, nor was the cellular membrane affected. 
The skin was the only organ diseased. Death was the 
result of the morbid condition of the fluids, engendered 
by a malignant miasm. 

Isolated cases of erysipelas gangrenosum may occa- 
sionally be seen, in all our hospitals, affecting adults. In 
former times it raged epidemically. We read that 
during the middle ages, the gangrenous erysipelas fre- 
quently ravaged France, where the disorder was called 
the plague of fire (ignis sacer). 

Such are the phenomena of what may be called 
superficial erysipelas, or what some authors have called 
erysipelas phlyctaenodes. It is not often, however, that 
the skin alone receives the whole force of the febrile 
commotion. We must inquire therefore, next, what 
happens, during the course of erysipelatous fever, to the 
neighboring textures ; and what other organs suffer. 



224 ERYSIPELAS PHLEGMONODES. 

In almost all severe cases of erysipelas, whether 
affecting the face or extremities, the subjacent cellular 
membrane participates in the disease. Inflammation 
spreads to it, and, from the peculiar texture and dis- 
position of this tissue, leads to the effusion either of 
serum or pus. When serum alone is effused, patholo- 
gists call the disease erysipelas cedematodes. When 
purulent matter collects, either in small abscesses, or, as 
more commonly happens, when it is diffused through 
the cells of the cellular membrane, we call the disease 
erysipelas phleg?no?iodes. You will understand that all 
these are only modifications of the same disorder, 
attributable to the varying intensity of the inflamma- 
tory action, or some peculiar malignity of the exciting 
cause. 

Tn the progress of erysipelas no organ is more likely 
to suffer than the brain. Pathologists are in the habit 
of saying, that a metastasis has taken place to the 
brain, but it is more properly extension of disease than 
change of locality. The external parts continue to be 
red, swollen, and blistered. Phrenitis, with delirium of 
a fierce kind, is sometimes witnessed. At other times, 
coma and stertorous breathing supervene, and the 
patient dies apoplectic on the seventh or eighth day of 
the disease, sometimes even later. Dissection seldom 
displays anything more than turgescence of the cere- 
bral vessels. These cases are singularly untractable. 
Instances of recovery have occurred, but the greater 
proportion of cases of erysipelas (especially of the 
face) complicated with phrenitis, or coma, prove fatal, 
and that very rapidly. 

[The recommendation of wine and other stimulants in the treatment 
of the delirium of erysipelas shows that our author fully recognises what 



ERYSIPELAS OF THE BRAIN. 225 

we believe to be an important practical principle, that there is a form of 
mental disturbance in this disease entirely different from that depending 
upon phrenitis, described by him, and characterized by a hot skin, 
strong- pulse, injected eyes, &c, and connected, indeed, with a pathological 
state directly opposite in its nature ; though no allusion to such a form 
is made under this head.] 

Occasionally, the stomach is the organ which suffers 
during the progress of erysipelas. I attended, many 
years ago, a gentleman of feeble frame, who, after a 
severe attack of initiatory fever, threw out erysipelas. 
The stomach, irritable at first, never recovered its tone. 
Vomiting continued, and so exhausted the patient that 
he died in one week from the seizure. In some 
instances, erysipelas, especially when it occupies any 
large portion of the surface, seems to affect the heart 
sympathetically. There is frequent syncope, with an 
exceedingly feeble pulse. Death takes place here by 
exhaustion, unless the system can be supported in the 
meantime by wine and brandy. Children attacked by 
erysipelas often perish by supervening mucous enteritis. 

[Mr. Robert Adams states [Dublin Hospital Reports, vol. iv.) two 
cases of erysipelas of the head and face, one traumatic and one idio- 
pathic, which terminated fatally by metastasis to the serous membrane 
of the heart ; and also alludes to two other cases of a similar nature 
seen by others, and a specimen of the morbid appearances presented by 
the dissection of another similar case, preserved by Mr. Cusack in the 
museum in Park street. (Amer. Jour. Med. Sci., vol. i. p. 433.)] 

These intimations of the several sources of danger and 
of death in erysipelas will preclude the necessity of any 
formal inquiry concerning prognosis. I will merely 
observe that erysipelas of the face is, cceteris paribus, 
more dangerous than erysipelas of the extremities. 
Nevertheless, gangrene is rarely observed as a con- 
sequence of erysipelas faciei. This termination is more 

15 



226 STATISTICS OF ERYSIPELAS. 

frequent in the erysipelas of parts at a distance from 
the heart (the scrotum and extremities). Erysipelas 
faciei most commonly proves fatal by supervening 
affection of the brain. 

[Colles says (Lectures on Theory and Pract. Surgery), " delirium or 
coma coming on before the local inflammation, does not indicate dan- 
ger ; but this is not the case when the eruption, accompanied by slight 
constitutional symptoms, has already continued for two or three days."] 

Erysipelas is most to be dreaded in weakly habits, 
and constitutions exhausted by previous illness. Ery- 
sipelas from miasm and contagion is more dangerous 
than erysipelas from internal causes. The extremes of 
life suffer from it more than the middle periods. 

[For an account of a form of erysipelas which has prevailed at differ- 
ent periods within a few years past in various parts of this country, 
under the name of " Black Tongue," see Appendix K] 

With reference to statistics, I have not much to tell 
you that can be relied on. When the inquiries now in 
progress in the several London hospitals, under the 
guidance of the Statistical Society, are fairly carried 
out, and an average of years taken, much will be 
elicited on this subject that is curious and edifying. 
At present, all is guess-work. It has been conjectured 
by Dr. Williams that the rate of mortality varies from 
one in three to one in fifteen (thirty-three per cent, 
down to six or seven per cent). With respect to the 
actual numbers perishing by erysipelas, we learn from 
the registrar general's reports, that in the metropolis, 
during the five years, 1838, 1839, 1840, 1841, 1842, the 
deaths by erysipelas have been respectively as follows : 
—405, 301, 311, 251, 235. Throughout England and 
Wales, the deaths by erysipelas were, in 1838, 1203 ; 



STATISTICS OF ERYSIPELAS. 227 

in 1839, 1140; in 1840, 1217. The steadiness of 
these numbers will attract your attention, so different 
from the fluctuations of the true exanthemata. You 
will notice at the same time that erysipelas is compara- 
tively more prevalent and more fatal in the metropolis 
than in the provinces. The general mortality of the 
one, compared with the other, is as four to one, but in 
the case of erysipelas, it is as eight to one. Such a 
result might have reasonably been anticipated from a 
knowledge of the character and constitution of the 
parties admitted into the hospitals and parochial infir- 
maries of London, and also from considering the com- 
parative purity of the air in town and country hospitals. 
Females unquestionably exhibit more cases than 
males in point of number, as already noticed ; but this 
is compensated by the greater intensity of erysipelas in 
males (from drink, mental excitement, &c), so that, in 
fact, as many males die of this disease as females. In 
1838, there died (throughout the country) 605 males, 
598 females. In 1839, 550 males, 590 females. In 
1840, 450 males, 456 females. In the metropolis, the 
proportion of male deaths exceeds slightly those of 
females. 

[Of 420 deaths by erysipelas in New York from 1837 to 1844 inclu- 
sive, 200 were males and 220 females. Great inequality prevailed 
during individual years of this series^ sometimes in favor of one sex, and 
sometimes in favor of the other. Of 254 deaths by this disease in 
Philadelphia, during the period from 1837 to 1845 inclusive, the num- 
ber of those of the two sexes was precisely equal ; but, as in New York, 
there was great inequality of the two sexes in individual years of the 
series.] 

In like manner, all ages seem to suffer in nearly the 
same degree. There died of erysipelas in London 
during the two years 1840-41, 562 persons, of whom 



228 



TREATMENT OF ERYSIPELAS. 



172 were under fifteen years of age, 265 were adults 
in the prime of life, and 123 were aged above sixty. A 
more minute investigation, however, establishes that 
the aged are its chief victims. If we compare the 
number of deaths with the numbers living at each 
respective period of life, we shall find that erysipelas is 
most fatal in advanced life, less so in early life, and 
least so in middle life. The proportions are expressed 
by the figures 55, 15, and 11. 

[Ages of 420 persons who died of Erysipelas in New York, during 
the eight years from 183*7 to 1844 inclusive, and of 254 who died of 
the same disease in Philadelphia, during the nine years from 1837 to 
1845 inclusive : — 



New York. 




Philadelphia. 


One year and under, 


133 . . 94 


Between 1 and 2 years, 


24 . 






11 


" 2 and 5 " 


29 






. 13 


" 5 and 10 " 


8 . 






6 


" 10 and 20 " 


. 22 . 






9 


" 20 and 30 u 


. 48 






. 13 


" 30 and 40 " 


63 






. 23 


" 40 and 50 " 


. 32 . 






. 24 


" 50 and 60 " 


. 22 






19 


60 and 70 " 


18 






. 14 


" 70 and 80 " 


13 






16 


" 80 and 90 " 


5 






. 11 


90 and 100 " 


. 2 






1 


Unknown .... 


1 






. 



420 



254] 



We come now to the thorny subject of treatment 
Erysipelas is obviously a highly inflammatory complaint. 
It displays most strikingly all the phenomena of inflam- 
mation — pain, heat, redness, swelling. Nevertheless, 
physicians for more than a century past have been 
divided as to the proper mode of treating this inflamma- 



BLOOD-LETTING AND PURGATIVES. 229 

tion. Some contend for bleeding, purgatives, and the 
usual antiphlogistic measures. Others still more forcibly 
urge the adoption of bark, wine, and a system essen- 
tially tonic. The great authorities are ranged pretty 
equally on both sides. Cullen, Lawrence, Dupuytren, 
are opposed by Drs. Wells, Willan, and Fordyce. 
Some who recommend wine object to bark, and at all 
events deny to bark that specific power over erysipelas 
which Dr. Wells and Dr. Powell claim for it 

Out of this mass of conflicting opinion it is difficult 
to extract any decided rule of practice. Facts are 
opposed to facts. Statistical inquiries, carefully con- 
ducted so as to guide our judgment, are wanting. In 
this emergency I must tell you what I have noticed 
myself, and what I believe you will find to be the safest 
course to pursue. 

We have seen that erysipelas arises from a great 
variety of causes, and may display itself under circum- 
stances the most opposite. It may happen to the ple- 
thoric soldier and the exhausted inmate of a workhouse. 
It may invade a young man in the prime of life, and a 
female of hysterical habit and feeble powers. It may 
arise from a depressing miasm, and it may follow a 
debauch of wine. Common sense dictates that any 
disease so occurring must be met by corresponding dif- 
ference of treatment. 

As an army surgeon, you will often find it necessary 
to bleed largely in erysipelas. If the pulse be full, the 
tongue deeply loaded, and the urine of the color of 
brandy, nothing but full bleeding from the arm will 
meet the exigencies of the case. I remember, some 
years ago, being called to attend a young man in erysi- 
pelas, aged about twenty-one, the apprentice of a 



230 STIMULANTS. 

butcher near Bond street. He was of gross habit, and 
the disease (in the facial form) was very intense. I 
bled him largely, with great benefit. The blood was 
sizy. At the Small Pox Hospital, even where the dis- 
ease was distinctly traceable to miasm, so depressing, in 
general, in its effects, I have often bled one patient, 
and given his next neighbor wine and brandy. Be 
guided, then, by the pulse, and never, when the pulse 
is full and hard, and the tongue deeply loaded, be 
deterred by any speculative considerations from taking 
blood. 

But supposing the symptoms are not in sufficient 
intensity to warrant the detraction of blood from the 
arm, still the other parts of the antiphlogistic system 
may be beneficially pursued, more especially purging. 
T received a good lesson on this subject some years ago 
from a boy under erysipelas. He had two mixtures 
given him, one, a simple saline — the other, an active 
aperient solution, containing salts and jalap. The boy, 
after experiencing the effects of both, begged me to 
persevere with the latter, and to spare him the former. 
I did so. The boy took his laxative draught twice a 
day, and made a rapid recovery. The best forms of 
aperient for erysipelas are calomel and rhubarb, senna 
and salts, castor oil, and the compound powder of 
jalap. Saline medicines are of very little service in 
erysipelas. 

When the pulse is small, the extremities cold, and the 
evidences of constitutional debility great and unequi- 
vocal, wine must be given in quantities proportioned to 
the exigencies of the case. 

Delirium is no bar to the employment of wine. This 
symptom is often checked in the most remarkable man- 



TREATMENT OF ERYSIPELAS. 231 

ner by wine. Many circumstances concur to prove 
that the delirium of erysipelas is not dependent on 
inflammatory action within the encephalon, but is akin 
to that which ushers in the confluent small pox. In 
some cases, the heart would cease to beat but for the 
constant stimulus of wine, or of warm brandy and 
water. 

Under certain circumstances, a mixed plan of treat- 
ment must be pursued. The liver must be stimulated 
and the bowels unloaded by calomel, jalap, and rhubarb, 
while the patient may take during the day a mixture 
containing the decoction of bark and the citrate of 
ammonia, with a proportion of aether. An opiate at 
night, such as the pulv. ipec. compos., with a few grains 
of the hydr. cum creta, to prevent any injurious effects 
on the secretion of the liver, may be advantageously 
directed. 

[The treatment of erysipelas must vary in different epidemics. In 
the one alluded to in Petersburgh, in 1844-45, that found most 
successful was the antiphlogistic. Venesection was sometimes very 
useful, but only " in a small minority of cases." Blisters often afforded 
marked relief, and were never attended by bad consequences. (A?ner, 
Jour. Med. Sci, Jan., 1846.) 

In the epidemics of the disease which have prevailed in different 
parts of this country within a few years past, the antiphlogistic plan of 
treatment has most generally been found to succeed best, and venesec- 
tion has often proved of great service. But it should be remembered, 
that the epidemics in which this plan of treatment, and especially blood- 
letting, has seemed to be most successful, have occurred in rural districts, 
and affected a class more likely to be favorably influenced by such 
measures than inhabitants of cities, among whom the mixed plan of 
treatment described by our author is found much preferable. In hospi- 
tals, especially, it is rare that depletion to any extent can be borne ; on 
the contrary, supporting means are often called for from the commence- 
ment. The same is true in certain epidemics, even among the strong 
and robust in the country. 



232 LOCAL TREATMENT. 

When the disease affects the face and head, it is important to keep 
the patient in an inclined posture in bed, so that the head may be 
elevated ; and also to keep it uncovered, to prevent accumulation of 
heat. 

Particular care should also be taken to keep the part elevated when 
either extremity is affected.] 

If physicians have differed on the constitutional 
treatment of erysipelas, they have not agreed better 
with regard to local treatment. Some advise warm 
applications, some cold ones. Some recommend watery, 
some spirituous fomentations. Some banish all fluid 
applications, and place their sole reliance on dry hair 
powder. A few would counsel us to cover the affected 
surface with mercurial ointment. Others have great 
confidence in lotions containing lunar caustic ; and a 
few, in their admiration of this remedy, pretend to con- 
trol the advance of erysipelas by surrounding the affected 
part with a ring touched by the lunar caustic, and say- 
ing to the inflammation — " Hitherto shalt thou come, 
and no farther." Here and there a practitioner, some- 
what more energetic in his notions, applies a blister to 
the very centre of the inflamed surface. 

I shall not occupy your time by minute criticism on 
these several modes of practice. All of them have, at 
times, proved useful — that is to say, patients have done 
well under them all. In truth, it would be as absurd to 
limit the local, as it would be to confine the constitu- 
tional treatment to any precise detail. The feelings of 
the patient may often be consulted advantageously, and 
that plan adopted which best moderates the sensation 
of heat and fulness which is so distressing to him. 
You must not expect much decided benefit from any 
kind of local treatment in a disease of constitutional 



LOCAL TREATMENT. 233 

You are not to neglect any means, however appa- 
rently trifling, which contribute to the ease and tempo- 
rary comfort of the patient, but you are not to exagge- 
rate the importance of external treatment, or to imagine 
you have made a great discovery, when you find a 
patient prospering better under a decoction of poppies 
than under a cold spirit lotion. 

In mild cases, the surface may be covered with hair 
powder. In severe cases, the affected parts may be 
painted with a lotion composed of a drachm of lunar 
caustic dissolved in eight drachms of distilled water, 
with eight drops of diluted nitric acid added. 

I have left to the last the great bone of contention, 
touching the propriety of local bleeding in erysipelas. 
This question admits of being viewed in a great variety 
of aspects. Mr. Lawrence and Mr. C. Hutchinson 
contended for the honor of this improvement in the 
treatment of erysipelas. I will state to you, in a few 
words, my own opinion on the subject. In erysipelas, 
there is undoubtedly great congestion of the superficial 
vessels, and, therefore, a priori, great benefit might be 
anticipated from the detraction of surface blood. Under 
careful management, and with due regard to the powers 
of the system, scarifications in erysipelas may be prac- 
tised with great benefit upon the extremities. I have 
my doubts as to the propriety of employing them on 
the face. I enter my protest, however, most strongly 
against those deep incisions through the entire thick- 
ness of the inflamed and swollen chorion which some 
surgeons have recommended. If the object be to 
obtain a large quantity of blood, that object would be 
gained more safely, and as effectually, by venesection. 
It is difficult, in all cases, and impossible in some, to 



234 LOCAL TREATMENT. 

control or limit the loss of blood proceeding from the 
gaping lips of a deeply incised erysipelatous surface ; 
and I need scarcely tell you that exhaustion from the 
excessive loss of blood in such a disease as erysipelas is 
a very serious evil. Many cases of erysipelas have 
undoubtedly been benefited by the detraction of surface 
blood, but many thousands of equally severe cases have 
done well without it. 

[Although we fully agree with our author iu the small amount of 
confidence to be placed in local remedies in an affection so manifestly 
connected with constitutional causes, as is the case with erysipelas, and 
have indeed ourselves seen but little effect from them in arresting the 
progress of the disease, we have thought that a notice of those which 
have been recommended by high authority, and are more or less in 
common use, might not be unacceptable — the more especially as some 
of them are at least palliatives, and often serve to soothe the local irrita- 
tion, and thus contribute materially to the comfort of the patient. 

Mercurial ointment has had many warm advocates as a topical appli- 
cation in erysipelas. 

Lisfranc thought that lard itself is a good local application in this 
affection, and that it may be substituted for mercurial ointment. He 
says that it should be renewed every two hours, and even every half 
hour, if the parts are hot and the weather warm. 

M. Jobert recommends ointment of nitrate of silver, which he uses of 
three degrees of strength, according to the intensity of the disease, 4, 8, 
and 12 parts to 30 parts of lard, to be applied freely. He also applies 
compresses, wet with tinct. camphor in the simple form. M. Jobert 
says, however, that local remedies have no effect in arresting the pro- 
gress of the disease on the skin ; but that ointment of nitrate of silver 
may be applied to shorten its duration on the part affected, and pre- 
vent the inflammation from extending to deep-seated parts. 

M. Trousseau has lately used locally, from the first day, and during 
the whole duration of the disease, lint dipped in a solution of camphor 
in ether, and applied five or six times daily. This may be used in cases 
of infants. (Bullet. Gener. de Ther., Feb., 1848.) 

M. Chomel has never found blisters, nitrate of silver, or mercurial 
ointment, either limit or arrest the progress of the affection. He says 
that the contradictory reports of the effects of certain topical applications 



LOCAL TREATMENT. 235 

may perhaps be traced to the difference in cause in different cases, 
whether external or internal, a distinction of practical importance. 

Mr. Liston recommends aconite (tinct. of root), both externally and 
internally, and Dr. Fleming has used it with marked benefit in several 
cases. 

M. Mojon has found a solution of tartar emetic, applied continuously 
by means of compresses, very efficacious as a topical antiphlogistic. It 
may be used tepid, but is better cold. (Annales de Ther., Jan., 1846.) 

Creasote has also been used and highly extolled, but is probably 
equally inefficacious with the articles above enumerated. 

Raw cotton has been used both in this country and elsewhere, and, 
as is said, with benefit as a topical remedy in this affection. The 
analogy between erysipelas and the first stage of a burn first led to this 
use of it. 

M. Velpeau speaks highly of sulphate of iron as a topical remedy of 
decided value. He uses it both in the form of a wash and of an oint- 
ment — the former in the proportion of 5 j to a pint of water — the part to 
be kept wet with it ; the latter in the proportion of about 3ij to §j, to 
be applied every second or third hour. 

A mixture of equal parts of spir. mindereri and tepid water is also 
recommended. 

The following cold lotion mentioned by our author in his Theory 
and Practice of Physic, has been found very grateful to patients, and 
has been extensively used in the New York Hospital : — &■ Liq. ammon. 
acet. 5iij ; spir. vin. 5j ; aqu. fontan. ixij. M. f. lot. 

Dry powders sometimes heat and irritate the skin, and their use is 
forbidden by some ; while, on the other hand, they are favorite applica- 
tions with others. M. Briquet has used collodion with success as an 
external application, especially in E. ambulans. The affected part must 
be covered with it daily. (Gaz. des Hopit, Oct. 1, 1850.) 

A decoction of cantharides in spirits of turpentine was introduced into 
practice some years since by Dr. Hartshorne of Philadelphia, as a 
topical application in erysipelas, in those of a relaxed habit, and in the 
typhoid form of the disease, and has been employed to some extent. It 
is prepared by boiling one ounce of cantharides in four ounces of spirits 
of turpentine, in some glass vessel (as a Florence flask), in a sand-bath. 
This is to be diluted with olive oil, and linen cloths wet with it to be 
kept applied to the affected parts. 

Different modes of local depletion in erysipelas have been recom- 
mended by surgeons of distinction, each claiming for his own an advan- 



236 LOCAL TREATMENT. 

tage over that practised by others. Some advise extensive incisions ; 
others, short incisions ; others again, punctures with the point of a 
lancet ; while some prefer to take blood by leeches. We have used 
free incisions with marked benefit in erysipelas affecting the limbs, espe- 
cially when there is great tension — this is at once relieved, at the same 
time that the part is freely depleted. Neither small incisions nor punc- 
tures accomplish either of these objects, nor do leeches effect it so 
promptly. M. Chomel forbids the application of leeches near the 
affected part, for fear of extending the inflammation. 

Both punctures and incisions should be followed by warm fomenta- 
tions or emollient poultices, and should be repeated if the tension is not 
relieved. Neither of these modes of depletion should be used except 
in the florid, raised form of erysipelas, with distension of the cellular 
membrane. Tincture of iodine and nitrate of silver are thought better 
adapted to the atonic form, characterized by a dusky hue.] 



LECTURE X. 

HISTORY, PHENOMENA, AND PRACTICE OP 
VACCINATION. 

Earliest notices of cow pox. Devotion of Jenner to this subject. An- 
nouncement of the discovery of vaccination. Its rapid adoption over the 
whole world. Insusceptibility of cow pox in certain persons. Pheno- 
mena of vaccination- Progress of the vesicle. Constitutional symptoms 
accompanying. Anomalies and varieties. Value of the cicatrix as a test 
of vaccine influence. Modified cow pox. Bryce's test. Concurrence of 
small pox and cow pox. Surgery of vaccination. Selection of efficient 
lymph. Mode of operating. Preservation of vaccine lymph. 

The act of 1840, commonly called the Vaccination Ex- 
tension Act, — though not nominally, yet in its practical 
working, is an act for enforcing the practice of vacci- 
nation on the whole population of these kingdoms ; for 
with the penalties of that act staring us in the face, our 
only choice lies hetween accepting vaccination, or 
exposure to the casual small pox. The latter alternative 
has coupled with it the passage through life in a state of 
constant and miserable suspense, the disorder perhaps 
seizing upon the individual at last under circumstances 
the most distressing — possibly, after having married, and 
become the father of a family, all of whom are depend- 
ent upon him for support. No parent in his senses 
could seriously hesitate when such an alternative is set 
before him. The whole population of England and 
Wales, therefore, are virtually by this act compelled to 
submit to vaccination, whether they like it or not. 
Formerly the case was different. Inoculation was 
allowable, and if people adopted vaccination, it was 



238 EARLIEST NOTICES OF COW POX. 

their own act and deed, for which no one could be 
blamed. Now the government of the country inter- 
poses, and takes the responsibility on its own shoulders. 
The measure was a strong one, but it had been adopted 
in foreign countries, and found to answer. It renders 
more than ever necessary, that everything connected 
with vaccination should be carefully studied by you — its 
history, pathology, phenomena, and practice. These 
points will occupy our attention during the present lec- 
ture. I shall, on a subsequent occasion, speak to you 
concerning the practical results of vaccination, and the 
statistical details by which we have, after an experience 
of forty-five years, arrived at a knowledge of its real 
efficacy. 

The earliest notice I have ever seen of cow pox is to 
be found in a weekly paper published at Gottingen, in 
1769, where we learn that such a complaint was not 
uncommon in the neighborhood of that town, and that 
those who caught it from the cows flattered themselves 
they were secure from the infection of small pox. A 
notion of the same kind had long prevailed in Glouces- 
tershire — a great dairy county, as you know,— and had 
often been forced upon the attention of the provincial 
surgeons. But no one thought seriously of this rural 
tradition, or dreamt of applying it to the general benefit 
of mankind, until Jenner arose. Dr. Jenner was born 
at Berkeley, in Gloucestershire, on the 17th May, 1749. 
He displayed an early taste for natural history, and was 
thrown from infancy among dairies and dairy maids. 
There he heard of the cow pox, and appears, almost 
from the first, to have foreseen the uses to which it 
might be turned. 

In the year 1770, being then twenty-one years of 



DEVOTION OF JENNER TO THE SUBJECT. 239 

ago, Jenner came to London, to prosecute his medical 
studies under the eye of John Hunter. To that 
enlightened man he repeatedly mentioned the popular 
rumors prevalent in Gloucestershire concerning cow 
pox ; but he does not seem to have received much 
encouragement to prosecute the inquiry. In 1775, 
being then engaged in practice at Berkeley, he devoted 
more attention to the subject. He often talked the 
matter over with his professional friends and neighbors. 
Among them was Mr. Fewster, of Thornbury, who 
had, in his early days, been associated with Sutton, the 
great inoculator. This circumstance naturally inspired 
him with a warm interest in everything connected with 
small pox, but he never would believe in the prophylac- 
tic power of cow pock. Other professional friends, in 
like manner, dissuaded Jenner from wasting his time on 
what they thought a barren study. " We have all 
heard of these stories," they would say ; " but the real 
cause of the anomaly is some peculiarity of habit in the 
person who escapes, not any efficacy in the disorder 
received from the cow." 

These and such like arguments would have effectually 
damped the ardor of most men ; but though discouraged, 
Jenner was not to be driven from his favorite pursuit. 
No opportunity was neglected by him which seemed 
likely to throw additional light on the subject. Cow 
pox appeared to be the object for which he mainly lived. 
He searched out all conceivable sources of failure. He 
learned to discriminate the various forms of eruption to 
which the teats of the cow are subject at different 
periods of the year, and was led to the belief that one 
only was possessed of specific or antivariolous powers. 
This he called true cow pox. The others he termed 



240 ANNOUNCEMENT OF THE 

spurious cow pox. By degrees he convinced himself 
that all the anomalies supposed by his professional 
brethren to be insurmountable obstacles to the success 
of his pursuit, were explicable on scientific principles ; 
and that cow pox was, what the uninstructed believed 
it to be, a true, full, and efficient preservative against the 
small pox. 

It would seem that about the year 1780 he first con- 
ceived the magnificent project of perpetuating and pro- 
pagating this disease by inoculation, and thus extending 
its benefits to the whole world. In 1788, he visited 
London, and carried with him a drawing of the casual 
cow pox as it appears on the hands of the milkers. 
This he showed to Sir Everard Home and other great 
men of that day, but the physicians of London saw in it 
only a curious and barren fact. Dr. Adams, physician 
of the Small Pox Hospital, noticed the cow pock in his 
" Treatise on the Morbid Poisons," published in 1795. 

It is a very curious circumstance that so far back as 
1782, when Dr. Archer was physician of the Small Pox 
Hospital, Catharine Wilkins, from Cricklade, in Wilt- 
shire, who had had the cow pox casually during early 
life, was tested with variolous matter at the Small Pox 
Hospital, and found to be unsusceptible. 

It was not until the year 1796 that Jenner began to 
experiment with cow ^ox, although he had been talking 
and inquiring about it for at least thirty years. The 
decisive experiment was made on the 17th May, 1796, 
on a boy, named Edward Phipps, eight years of age. 
He was tested with small pox on the 1st of July of that 
year, and found to be unsusceptible. 

Jenner now prepared for publication, and sent his 
paper, carefully and very philosophically drawn up, to 



DISCOVERY OF VACCINATION. 241 

the Royal Society, wishing that the discovery should 
come forth to the world under its high auspices ; but 
that learned body declined to receive the paper, lest it 
should injure Jenner's fame, already established by some 
observations on the cuckoo ! Jenner, nowise discon- 
certed, published the paper himself in June, 1798. 

The work was drawn up with singular skill. An 
air of philosophical calmness pervaded it, which was 
highly attractive. It was not the hasty production of a 
young man anxious to push himself into early notoriety, 
but the mature opinion of a physician whose life had 
been devoted to a deep and careful consideration of his 
subject, and who staked his professional reputation on 
the success of the measures which he recommended. 
It is not to be wondered at, that a volume, published 
under such circumstances, mole parvwn, materia gravem, 
should have riveted the attention not of physicians 
alone, but of the whole civilized world. 

It redounds to the honor of St. Thomas's Hospital, 
that its medical officers were the first persons in England 
to put Jenner's discovery to the test. Mr. Cline vac- 
cinated a boy here, in the last week of July, 1798, with 
dried lymph, which had been kept three months on a 
quill. The boy had diseased hip, and Mr. Cline, pro- 
posing to convert the vaccine pock into a pea issue, 
inserted the matter on the outside of the hip. Dr. 
Lister, formerly physician of the Small Pox Hospital, 
watched the progress of the case. The boy was inocu- 
lated almost immediately afterwards, with small pox 
matter, in three places, but the slight inflammation that 
arose subsided on the fourth day. The experiment 
therefore was perfectly successful. 

On the 20th January, 1799, cow pock was found in 

16 



242 HISTORY OF VACCINATION. 

Mr. Harrison's dairy, in Gray's Inn Lane, from which 
source, Dr. Woodville, my predecessor at the Small Pox 
Hospital, commenced a series of vaccinations. That 
same stock of lymph remained in use up to the year 
1836. 

To pursue the triumphant career of vaccination would 
be gratifying to me, but it would not conduce to your 
improvement. Suffice it to say, that the new practice 
was received with enthusiasm, not only in this country, 
but over the whole of Europe. It reached India in 
1802, and penetrated with equal rapidity into the wilds 
of America ; for foreign nations vied with us in efforts 
to extend the beneficial practice to the farthest regions 
of the globe. 

[Vaccination was first practised in this country by Dr. "Waterhouse, at 
Boston, in July, 1800, with matter received from Dr. Jenner himself. 
He used it first upon four of his own children, who, consequently, were 
the first vaccinated persons in the United States. 

Dr. Miller, of this city, received vaccine matter from Dr. Pearson, of 
London, the same year, but it failed to produce the genuine disease ; as 
did also another supply of matter sent on from Boston. (Thacher's 
Amer. Med. Biography.) 

The credit of its first successful performance in this city is, therefore, 
due to Dr. Valentine Seaman, who obtained matter first from the arm 
of a domestic vaccinated in Boston by Dr. Waterhouse, who reached 
this city on the 22d of May, 1801, just at the proper time for the matter 
to be used. With this, his first supply, he vaccinated eighteen persons, 
when, in consequence of being prevented by severe illness from pursuing 
the subject, the infection was lost. In the course of the following win- 
ter, however, he obtained a fresh supply, and by the 2 2d of December, 
1802, thirty -five others had undergone the disease, making the whole 
number fifty-three, without his having obtained a single co-operator. 
{Medical Repository, vol. v. p. 236 ; also, Discourse upon Vaccination, 
by Valentine Seaman, M.D., 1816.)] 

A few detached notices will complete my sketch of 
the history of cow pox. In 1807, Parliament voted to 



INSUSCEPTIBILITY OF COW POX. 243 

Dr. Jenner a sum, amounting, in all, to £30,000, as a 
reward for his discovery, and the generous devotion of 
his time and talents to the public welfare. In 1808, 
the National Vaccine Establishment was formed, and 
the support of government given to this measure, though 
not in a very efficient form. 

In 1823, Dr. Jenner died at Berkeley, the scene of 
his early labors, full of years and honors. 

In 1840, a Bill passed the legislature for the exten- 
sion of the practice of vaccination throughout England, 
Wales, and Ireland. The machinery of this act was 
placed under the supervision of the poor-law commis- 
sioners. Payment to medical practitioners is directed to 
be made, at a stipulated sum (averaging one shilling 
and sixpence) for each successful case ; such expenses 
to be defrayed out of the poor rate. A still later act 
confirms these provisions, with a few unimportant addi- 
tions. This act is working well, and the practice of 
vaccination is now rapidly extending over the provinces. 
In the metropolis, owing to the number of well-con- 
ducted vaccine institutions, it had always prospered. 

Having thus brought down the history of vaccination 
to the latest period, my next object is to make you 
familiar with the several appearances which it presents, 
regular and irregular ; but before doing so, I must inform 
you that occasionally we meet with persons who, from 
some peculiarity of habit, are wholly insensible to the 
vaccine poison, in whatever intensity and by whatever 
mode it is applied. They receive it as they would so 
much cold w 7 ater. The proportion of mankind w 7 ho 
exhibit this singular idiosyncrasy is very small. I may 
have seen thirty or forty such cases in the course of my 
life. It would be very interesting to determine whether 



244 PHENOMENA OF VACCINATION. 

this constitutional inaptitude to cow pox denotes a like 
inaptitude to receive and develop the variolous poison. 
In the few cases which I have seen, where inoculation 
was subsequently tried, the insusceptibility was proved 
to extend to both poisons, but I have read of instances 
of an opposite kind. It is at all times very difficult to 
arrive at the truth, on a question of this nature; and 
now that inoculation is forbidden, we may despair of 
ever arriving at any certainty concerning it. 

The insusceptibility to the vaccine poison is, in some 
cases, obviously dependent on constitutional weakness, 
displayed in the slowness of dentition, the imperfect 
ossification of the head, and the emaciated aspect of 
body. There exists here an atony of the absorbent 
system. If vaccine lymph is inserted into the arm, 
either no vesicles arise, or they are small, and imper- 
fectly developed. In such cases, the indisposition to 
receive cow pox is only temporary. In the former 
cases, where idiosyncrasy is the cause of the phenome- 
non, the inaptitude continues through life. 

I now proceed to describe to you the phenomena of 
vaccination. 

The regular course of cow pox is as follows : — On 
the third day from the insertion of the virus, the wound 
will be perceived red and elevated. By aid of the 
microscope, the efflorescence surrounding the inflamed 
point will be distinctly perceived even on the second 
day. On the fifth day, the cuticle is elevated into a 
pearl-colored vesicle, containing a thin and perfectly 
transparent fluid in minute quantity. The shape of the 
vesicle is circular or oval, according to the mode of 
making the incision. On the eighth day, the vesicle is 



PROGRESS OF THE VESICLE. 245 

in its greatest perfection, its margin is turgid and sensi- 
bly elevated above the surrounding skin. In color the 
vesicle may be yellowish or pearly. The quantity of 
fluid which it contains will be found to vary much. 
When closely examined, the vesicle will exhibit a cellu- 
lated structure. The cells are tenor twelve in number, 
by the floor and parietes of which the specific matter of 
the disease is secreted The vesicle possesses the um- 
bilicated form belonging to variola. 

On the evening of the eighth day (counting from the 
day on which the incision was made), an inflammatory 
circle, or areola, commences at the base of the vesicle. 
The skin becomes tense, red, and painful, for a consi- 
derable extent around. The figure of the areola is per- 
fectly circular. In some cases the subjacent cellular 
membrane participates in the inflammatory action, and 
occasionally the glands of the axilla swell. The areola 
continues to advance during the ninth and tenth days. 
On the eleventh day it begins to fade, leaving, in its 
decline, two or three concentric circles of a bluish 
tinge. 

The vesicle, by this time, has either burst spontane- 
ously, or been opened by the lancet of the surgeon. Its 
contents now become opaque. The vesicle itself begins 
to dry up, and a scab forms, of a circular shape, and a 
brown or mahogany color. By degrees, this hardens 
and blackens, and at length, between the eighteenth 
and twenty-first day, drops off, leaving behind it a cica- 
trix of a form and size proportioned to the prior inflam- 
mation. A perfect vaccine scar should be of small size, 
circular, and marked with radiations and indentations. 
These show the character of the primary inflammation, 
and attest that it had not proceeded beyond the desira- 



246 CONSTITUTIONAL SYMPTOMS. 

ble degree of intensity. Many of the most perfect scars 
disappear entirely as life advances. 

Until the eighth day, the constitution seldom sympa- 
thizes. At that period, however, it is usual to find the 
infant somewhat restless and uneasy. The bowels are 
disordered. The skin is hot, and the night's rest is 
disturbed. These evidences of constitutional sympathy 
continue for two or three days. There is, however, 
much variety observable here. Some children suffer 
slightly in their general health throughout the whole 
course of vaccination. Others exhibit scarce any indi- 
cation of fever, although the areola be extensive, and 
the formation of lymph abundant. 

[In occasional, though rare cases, there is a general eruption of vaccine 
vesicles over more or less of the whole body, resembling in some patients 
those of varicella, and in others those of the genuine cow pock, and 
sometimes a mixture of the two. Two cases occurred among those 
vacciuated in France in 1840, in which there was a general eruption of 
pustules over the whole body, the fluid from which produced regular 
vaccinia. We have met with an instance of this general vesicular erup- 
tion over the body resembling vaccinia, but did not test the fluid con- 
tained in the vesicles. M. Aubry has also published a case of this kind. 
(Archives de Mtd., Paris, Sept. 1841.) 

In some instances, vaccine vesicles appear at other than the points of 
insertion of the virus, and sometimes on parts where no abrasion existed 
which could have been inoculated with it. We have seen a single 
vesicle on the finger of the arm vaccinated in an infant, and in another 
infant, one on the chin ; and in one case, the vaccine vesicles so numerous 
about the neck of an infant as to form, as it were, a band of them 
encircling the part, nearly an inch in breadth. This infant had suffered 
from an erythematous affection of that part, which had produced some 
excoriation of the surface. A second instance of the same kind came to 
our knowledge after the vesicles had entirely healed. In another ease, 
a child eighteen months old, vaccinated a fortnight before, had well 
characterized vaccine vesicles on the external labia, and also on the 
perineum, and about the anus. The vesicles bore some resemblance to 
certain forms of venereal eruption appearing about those parts in 



CONSTITUTIONAL SYMPTOMS. 247 

children, and the case was carefully examined with reference to this 
point. 

A very remarkable case has been recently reported by Dr. R. 0. Clark 
{Loud. Med. Gaz.j Nov. 8, 1850), of "a genuine cow-pox vesicle rising 
at another part than the point of insertion." A healthy looking child, 
nine months old, was vaccinated on the 28th of August, three incisions 
being made over the deltoid muscle of the left arm. On the 30th, there 
seemed a slight disposition to the formation of vesicles ; but all redness 
disappeared during the next day, and there were no other signs of its 
having taken effect on that part. On the evening of the 2d of Septem- 
ber, the mother noticed a small red pimple about the middle of the fore- 
arm, which Dr. C. recognised the next day as presenting all the charac- 
ters of a cow pox vesicle of about the third day after vaccination, and 
which ran regularly through all the stages of such a vesicle. He after- 
wards vaccinated the child at two different times with great care, with 
fresh matter, but without any effect, so that the character of the vesicle 
may be considered as fully established. He referred the matter to Dr. 
Gregory for his opinion, who told him, that " if the single vesicle were 
bond fide cow pox, the case was a very curious one indeed, undoubt- 
edly the first of the kind that ever happened." Dr. G. recommended 
the test of re-vaccination, after some laxatives to the child, and himself 
sent Dr. C. matter for the purpose, which was used without effect. Dr. 
G. stated that, although he had before seen constitutional vesicles, he had 
never seen them without unequivocal primary vesicle at the same time.] 

It is not uncommon to find the child's body covered, 
generally or partially, with a papulous eruption, of a 
lichenous character, from the ninth to the twelfth day, 
or even later. It is seldom seen in adult vaccination, 
but is frequent in children full of blood, in whom 
numerous vesicles had been raised, which discharge 
freely. Vaccine lichen, as this eruption is properly 
called, often occasions great anxiety in the mind of 
the parent, from a suspicion that small pox is coming 
out. I have seen it in such intensity as to be fol- 
lowed by minute vesicles ; but this latter appearance 
is very rare. It is an accidental occurrence, chiefly 
attributable to the peculiar delicacy of the child's skin, 



248 ANOMALIES AND VARIETIES OF COW POX. 

and fulness of its habit. Like the constitutional irrita- 
tive fever, it indicates that the disease has taken effect 
on the system, but it is not deemed essential to the suc- 
cess of the process. 

[In some cases, patches of roseola appear in the neighborhood of the 
place of insertion of the matter, and extend more or less along the arm, 
gradually disappearing as the areola fades. At other times, an erythe- 
matous or roseolar redness covers the palms of the hands and soles of 
the feet about the eighth to the tenth day, disappearing at the end of 
twenty-four or forty-eight hours, and requiring nothing but that its true 
character shall be recognised, so as to give the necessary explanation to 
friends. We may add, that the lichen described by our author as 
accompanying certain cases of vaccinia, may attend upon spurious as well 
as genuine vaccination, and hence cannot be regarded as any certain test 
of the efficacy of the operation.] 

The irregularities and anomalies of cow pox are 

various, and require to be specially described. The 

most singular variety of cow pox is the petechial, or 

that, where from some peculiarity of habit, the vaccine 

poison developes the haemorrhagic diathesis. Of this I 

have only met with one instance, recorded in the Med. 

Chir. Trans, (vol. xxv.p.253). Petechia?, haemorrhages, 

and an ecchymosed areola, were the characteristic 

features of this remarkable case. The child recovered, 

all haemorrhagic appearances having declined on the 

sixteenth day of vaccination. 

[A notice of this case may be found in the Med. Chir. Rev., Jan., 
1843, p. 29.] 

The most common irregularity is that wherein the 
vesicle, at a very early period of its course, becomes 
prematurely red and itchy, whereby the infant is 
tempted to rub or scratch it. To this rubbing the sub- 
sequent appearances are usually attributed, but most 
unjustly, for the same consequences follow, though the 
child's hands are muffled. In this irregular form of 



VALUE OF THE CICATRIX. 249 

vaccination, a small acuminated or conoidal pustule will 
be perceived on the sixth or seventh day, surrounded by 
a slight areola, of irregular shape. The contained fluid, 
instead of being a clear and transparent lymph, is 
opaque, and of a light straw color. The succeeding 
scab is small, and drops off prematurely. 

In some cases, the specific inflammation, or areola, 
proves very violent, extending from the shoulder to the 
elbow, and sometimes running into genuine erysipelas. 
The vesicle, instead of drying into a hard scab, is con- 
verted into an ulcer, discharging profusely,- and leaving 
behind it a large scar, of the size of a common wafer, in 
which neither rays nor depressions can be traced. Much 
temporary inconvenience, but no permanent ill conse- 
quence results. The poison has taken full effect upon 
the constitution upon the eighth day. All that happens 
afterwards is immaterial in respect to the security of the 
child. These facts w 7 ill enable you to decide on the 
degree of importance to be attached to the cicatrix as 
an evidence of the perfection or imperfection of the 
original vaccine process. In every country, this is the 
test chiefly trusted to, for in the course of twenty or 
thirty years all memory of the actual appearances is 
usually lost, and it is rare that any written record of 
them is preserved. A perfect cicatrix, that is, small, 
circular, radiated, indented, and persistent through life, 
is doubtless satisfactory proof that the individual pos- 
sessing it has passed through the regular cow pox, and 
has obtained from it all the protection which vaccina- 
tion is capable of affording ; but an imperfect cicatrix 
is no proof that such influence never had been felt, or 
that having been felt, it has subsided. Irregular cica- 
trices are compatible with full constitutional effect, 



250 ANOMALIES AND VARIETIES OF COW POX. 

because, as I have told you, they often depend upon 
irregularities commencing incidentally after the tenth 
day, when the specific influence has been completed. 
Even the total absence of cicatrix is not decisive 
against the present or prior existence of vaccine energy 
in the system ; for in many cases, the specific inflam- 
mation is moderate, and the resulting scar wears out in 
the progress of life, as other scars do, which are not the 
products of a specific poison. Perfect security is com- 
patible with a small and scarcely distinguishable cica- 
trix, with a large watery cicatrix, and with no cicatrix 
at all, at least none perceptible five years after the 
operation. 

[The committee appointed by the Provinc. Med. and Surg. Associa- 
tion, in their report in July, 1839, say that, by itself, the cicatrix ought 
never to be absolutely trusted. They add, " we are inclined to believe 
that, though the presence of a perfect cicatrix is not a sure sign of pro- 
tection, its absence must be held to speak strongly against the existence 
of vaccine influence." 

Abundant evidence might be adduced, if necessary, derived from 
extensive observation in the Prussian, Wirtemberg, and Bavarian 
armies, as well as on a smaller scale in other places, to show that no 
dependence can be placed upon the vaccine scar as an evidence of pro- 
tection from an attack of variola. Indeed, it may be considered as an 
established point, that such is the case.] 

Another variety of cow pox exhibits, about the sixth 
or seventh day, the vesicle partially inflamed and scaly. 
A species of psoriasis has taken the place of areola. 
Whether these and similar anomalies are to be held as 
depriving the cow pock altogether of its specific anti- 
variolous property, is a question not yet decided. 
Jenner contended, that under such circumstances, no 
reliance could be placed on it in after life; while on the 
other hand, Bousquet, a high authority, maintains that 



ANOMALIES AND VARIETIES OF COW POX. 251 

in such cases, constitutional influence is by no means 
impaired. It is doubtful how far confidence can be 
placed in so defective a process as this. 

Cow pox is occasionally retarded in its normal pro- 
gress. That this should happen in consequence of the 
prior occupation of the system by measles or scarlatina, 
you can readily understand. So likewise is it easy to see 
why this may be the result of an accidental bowel com- 
plaint. But sometimes the cow pock vesicle, without 
any such cognisable cause, is retarded for three, four, 
or more days. Retardation of the vesicle does not 
in any degree take from the ultimate security of the 
child. 

[Dr. Jenner early observed that the presence of certain forms of 
cutaneous disease, more especially the squamous and the vesicular, 
modified the progress of the vaccine vesicle, and stated that vaccination 
performed on a skin occupied by any of these diseases " produces every 
gradation, from that slight deviation from perfection which is quite 
immaterial, up to that point which affords no security at all." 

The committee of the Provincial Medical and Surgical Association 
say, " Wherever there is the slightest disturbance of vaccination mani- 
fested by a pre-existing cutaneous disease, the vaccination ought to be 
distrusted, and repeated as soon as the skin has been brought to a 
healthy state." — (Transac. Prov. Med. and Surg. Assoc, vol. viii. 
p. 31.) 

Mr. Sterry gives a case (Lond. Med. Gaz., April 9, 1847) of the 
influence of lepra on vaccination, and says that he did not remember an 
instance of successful and perfect vaccination in a patient the subject of 
cutaneous disease. 

Dr. Baron also reports a case of interruption of vaccination by cuta- 
neous disease, and others might be quoted. 

It is not, however, uniformly the case that the progress of the vaccine 
vesicle is impeded by the previous existence of cutaneous disease.] 

Small pox and cow pox are sometimes seen running 
their course simultaneously without mutual interference. 
At other times the cow pox is retarded. Occasionally 



252 ANOMALIES AND VARIETIES 

they mutually restrain and modify each other's action. 
Much depends on the time which has elapsed from 
the application of each germ respectively. As a gene- 
ral rule, it may further be stated, that extraneous fever, 
however excited, restrains the growth and modifies the 
normal progress of the vaccine vesicle. It never 
reaches perfection, unless the system be in a sound 
state. If, therefore, the variolous germ be received into 
the body quietly, and eliminate itself with little consti- 
tutional disturbance, vaccination may advance pari 
passu with the small pox, and complete its series of 
changes undisturbed. 

The following case strikingly illustrates this principle, 
and exemplifies at the same time the incubative period 
of small pox, and the law of exanthematic suspension : 
— William Bavin, getatis 27, coachman, from 15 Cur- 
zon street, visited his brother on Friday, February 3, 
1843, whom he found laboring under small pox. He 
took the precaution of being vaccinated on Monday, 
February 6 ; began to feel poorly Saturday, February 
11 ; obliged to leave off work, February 13. Eruption 
of small pox appeared on Wednesday, February 15, 
being the thirteenth day from exposure to contagion. 
Scarcely any fever was present. The small pox proved 
distinct and mild, and ran a perfectly normal course. 
The vaccine vesicles were retarded, so that both dis- 
orders maturated together. On Monday, February 20 
(the sixth day of variolous eruption, and the fourteenth 
of cow pox), the small pox pustules were well acumi- 
nated, and six vaccine vesicles were to be seen, full and 
finely developed. 

[The practical question of most interest connected with the reciprocal 
influence of vaccinia and variola upon each other is, as to the latest 



OF MODIFIED SMALL POX. 253 

period of time at which vaccination affords protection after exposure to 
the contagion of variola ; and on this point there seems to be some 
discrepancy of opinion. 

M. Legendre gives as his conclusions, from a comparison of fifty-six 
observations, derived from different sources, that while vaccination per- 
formed during the incubation of small pox, modifies the character of 
that disease, the vaccine disease itself is usually modified in a degree 
directly proportioned to the shortness of the interval between the per- 
formance of the vaccination and the appearance of the small pox. The 
areola is not so well marked, and there is no sub-cutaneous swell- 
ing. When vaccination is performed after the appearance of variola, 
the vaccine vesicle sometimes runs its course, but does not modify the 
variola. 

Dr. Tardieu relates a case (Archives Giner. de 3fed., 1845) of a 
young man vaccinated after the pustules of variola had appeared. The 
pustules reached the period of desquamation by the sixth to the eighth 
day, and there was no fever nor swelling of the face and extremities. 
At the tenth day of eruption, the vaccine points had undergone no 
change, but six days afterwards the patient stated that for five days 
past the vaccination seemed to have taken, and four vaccine pustules 
(the matter had been inserted in twelve or fifteen places in each arm) 
were then seen on the right arm, almost entirely dried up. It would 
seem from this as though vaccination is of service in those not vacci- 
nated, not only during the primary fever, but even at the commencement 
of the variolous eruption. 

Dr. L. V. Bell (of Derry, N. H.) states that he has minutes of cases 
in which there was no evidence of vaccination having taken effect until 
after exposure for seven, nine, ten, and eleven days, to small pox in its 
most malignant form, when the succeeding varioloid was of the mildest 
character. In these cases, however, the patients had been placed on a 
precautionary treatment and diet, and were usually vaccinated daily, 
until it was evident that the vaccine matter had taken. (Notice of his 
paper on Small Pox, Varioloid, and Vaccination — Amer. Jour. Med, 
ScL, May, 1836.)] 

Another variety of anomalous, or what is called 
modified cow pox, presents itself when the vaccine 
virus is reinserted on the fourth, fifth, or sixth day from 
the primary vaccination. The result is, that the vesi- 
cles of the secondary vaccination form rapidly, and are 



254 bryce's test. 

hurried forward in their course, so as to overtake the 
first crop, when the whole maturate and scab together. 
The secondary vesicles are thus necessarily much 
smaller than the primary. Mr. Bryce, in 1802, inge- 
niously proposed to avail himself of this law, with the 
view of ascertaining whether the system was under the 
full influence of vaccination. The plan, though it 
never received the sanction of Dr. Jenner, has never- 
theless enjoyed great popularity, and is everywhere 
known by the name of Bryce's test. He recommends 
that the second application of the virus should take 
place on the evening of the fifth or morning of the sixth 
day, so that the new vesicles may have from thirty-six 
to forty-eight hours to grow, before constitutional or 
irritative fever is set up. Of late years, this procedure 
has fallen comparatively into disuse. In cases where 
the primary vaccination proves unsatisfactory, it is now 
more usual to recommend a repetition of the operation 
at the interval of one, two, or three years, according to 
the extent of the apparent imperfection. I believe this 
to be a great improvement on the plan of Mr. Bryce. 

When re- vaccination is practised at distant periods 
from the primary insertion of the virus, the arm very 
generally presents the appearances of modified cow pox 
— that is, the vesicles advance with abnormal rapidity. 
Areola forms around them on the fourth or fifth day. 
The resulting scabs are small, and fall off in a few days. 
Much itching accompanies the process. In some 
cases, the renewed insertion of the virus occasions 
considerable local uneasiness, with more or less con- 
stitutional sympathy. I have seen re- vaccination in 
irritable habits occasion irregular and extensive areola, 
painful swelling of the absorbent glands, headache, 



SURGERY OF VACCINATION. 255 

general weakness and lassitude, and a strong disposition 
to recurring erythema of the arm. 

The surgery of vaccination, simple as it may appear 
to you, has nevertheless been a fruitful theme of con- 
troversy. Differences of opinion have existed with 
respect to the selection of lymph, the mode of making 
the incisions, and the number of incisions necessary to 
insure a full effect. Each of these points merits your 
attention. 

1. One of the earliest and most important disputes 
which chequered the career of vaccination (inasmuch 
as it led to the secession of Jenner, in 1807, from the 
original Jennerian Institution) had reference to the 
mode of taking the lymph. Dr. Walker adopted the 
plan of detaching the epidermis from the vesicle, and 
vaccinating with the lymph (or fluid) which exuded 
from the abraded floor of the vesicle.* Jenner objected 
strongly to this, and employed only the superficial 
lymph. Dr. Walker persevered in his plan ; and it is 
but fair to confess that his vaccinations have stood the 
test of time fully as well as those conducted according 
to the Jennerian method. 

The proper time at which lymph may be taken so as 
to obtain it in the most efficient state for propagating 
the disease, has also been a subject of discussion. Some 
have objected to the employment of very early lymph, 
others have scruples in taking lymph after the first 
appearance of areola, and all parties have concurred in 
condemning the use of lymph taken on or after the 
tenth day. The facts bearing on this question are as 

* " Report from the Select Committee of the House of Commons on the 
Vaccine Board ; 1833." Page 114. 



256 SELECTION OF EFFICIENT LYMPH. 

follows. The younger the lymph is, the greater is its 
intensity. The lymph of a fifth-day vesicle, when it 
can be obtained, never fails. It is, however, equally 
powerful up to the eighth day, at which time it is also 
most abundant. After the formation of areola, the 
true specific matter of cow pox becomes mixed with 
variable proportions of serum, the result of common 
inflammation, and diluted lymph is always less effica- 
cious than the concentrated virus. Nevertheless, very 
pure lymph, if not too long humanized, will often prove 
effective when taken from the arm on the ninth, and 
even sometimes on the tenth day. After the tenth day, 
the lymph becomes mucilaginous, and scarcely fluid, in 
which state it is not at all to be depended on. Out of 
a dozen incisions made with such viscid lymph, not 
more than one will prove effective. The scabs of cow 
pox, ground to powder, and moistened with lukewarm 
water to the consistence of mucilage, will sometimes 
reproduce the disease in all its purity, a satisfactory 
proof that the alteration which the lymph undergoes in 
its progress to maturity is not of a specific kind, liable 
to influence the result of the subsequent vaccination, 
but simply dilution. Experiments with diluted lymph 
were formerly made by Dr. Adams, at the Small Pox 
Hospital, and have since been repeated in France by 
M. Bousquet, and it is ascertained that effective vacci- 
nation may be thus produced. 

Cow pox matter differs in its character and qualities, 
according to the source from which it has been obtained. 
Healthy and well fed children afford a lymph much 
superior to that which is obtained from weakly and ill 
fed children, whose blood is thin and poor. Lymph 
being a product of blood, it is obvious that the purer the 



SELECTION OF EFFICIENT LYMPH. 257 

blood, the purer will be the lymph derived from it. 
But, further, experience teaches that the vesicles, even 
of apparently healthy children, are not equally fitted to 
reproduce the disease in purity. Some contain an 
acrimonious lymph which occasions irritable vesicles in 
all children, healthy and unhealthy, vaccinated from it. 
Such vesicles are with difficulty distinguished, even by 
a practised eye. A good vesicle, too, may be drained 
so much that the exuding lymph possesses little or no 
intensity. Infantile lymph is more to be depended 
upon than the lymph obtained from adults. The mat- 
ter of primary vaccinations is more energetic than that 
of secondary vaccinations. These statements may 
serve as a guide to you in the selection of lymph where- 
with to vaccinate. 

[It is much to be feared that sufficient attention has not heretofore 
been, and is not now always paid to the selection of good lymph. As 
well remarked by the committee of the Provinc. Med. and Surg. Associa- 
tion, " if a deviation commences, it may be perpetuated, and afford a 
gradually decreasing protection;" they add, "there is no doubt that 
lymph of this kind has been often used." 

The importance of the following rules laid down by that committee, 
renders them worthy of transfer to our pages : — 

" 1. The progress of the vesicle must be noted at suitable periods, to 
learn that it passes through its stages regularly. 

" 2. Lymph should be taken from the fifth to the eighth day, and be- 
fore the formation of the areola, a rule of Jenner, and which should 
always be observed. 

" 3. Lymph should never be taken from a vesicle which deviates in 
the least degree from the perfect standard, nor from a patient laboring 
under any cutaneous disease. 

" 4. One or more vesicles should always be left to run their course 
without being in any way disturbed. This ought always to be insisted 
upon. 

" 5. Whenever there is the slightest disturbance of vaccination mani- 
fested by a pre-existing cutaneous disease, vaccination ought to be dis- 

17 



258 MODE OF OPERATION. 

trusted, and repeated as soon as the skin has been brought to a healthy- 
state." 

Dr. Waterhouse, in a letter to Dr. Mitchell, dated Cambridge, Sept. 
26, 1801, says : "Yesterday I received a letter from Dr. Jenner, one 
paragraph of which I must transcribe, because it contains the golden rule 
of vaccination, viz. " I don't care what British laws the Americans dis- 
card, so that they stick to this — never to take the virus from a vaccine 
pustule for the purpose of inoculation, after the efflorescence is formed 
around it. I wish this efflorescence to be considered as a sacred bound- 
ary, over which the lancet should never pass." (Med. Repository, N. Y., 
vol. v. p. 236.)] 

2. The second subject for our consideration is the 
mode of making the incisions, so as to ensure the best 
and most certain results. Failure in the operation is 
always harassing to the friends, and is often made the 
pretext for delays dangerous to the child. Some sur- 
geons use a sharp, others prefer a blunt lancet. Some 
consider it necessary to make the wound very superfi- 
cial, others go deeper, and are careless whether much 
or little blood follows the incision. A few operators 
scarify the skin in numerous places, in preference to 
making incisions. I know very well that, provided the 
lymph be good, it matters little in what way the virus 
be applied, but the most uniformly successful mode is 
the following. Let the lancet be exceedingly sharp. 
It should penetrate the corion to a considerable depth. 
The notion that the subsequent effusion of blood will 
wash out the virus, and thus defeat our intention, is 
quite imaginary and groundless. Provided that a genu- 
ine lymph of due intensity has once come in contact 
with the absorbing surface of the cutis vera, the rest is 
immaterial. The vessels of the part have received the 
specific stimulus, and nothing can prevent the advance 
of the disorder but some constitutional cause. In 



NUMBER OF INCISIONS. 259 

making the incision, the skin should be held perfectly 
tense between the forefinger and thumb of the left hand. 
The lancet should be held in a slanting position, and 
the incision made from above downwards. 

3. The number of incisions which it is requisite to 
make, in order to produce a full constitutional effect, 
has been always a disputed point. At an early period 
of vaccination, one vesicle was held to be sufficient 
Then three, four, or six, were recommended. In Ger- 
many, great importance is attached to the raising of 
numerous vesicles, it being a received doctrine in that 
country, that unless some decided constitutional effect 
be produced, little reliance can be placed on the process 
as a security in after life. Common sense dictates that 
the greater the number of vesicles, the greater will be 
the local inflammation, the greater the probability of 
constitutional sympathy, and on this theory the greater 
chance of ultimate security. Some of the German 
inoculators have been in the habit of raising from 
twenty to thirty vesicles in each subject. In forming a 
just judgment on this matter, the nature and quality of 
the lymph must always be taken into account. Lymph 
recently derived from the cow possesses so much inten- 
sity, and fixes itself with so much more of a poisonous 
character upon the skin of the arm than lymph long 
humanized or habituated to the human constitution, that 
a single incision made with it is equivalent to six or 
eight made with lymph of minor energy. 

I would recommend that with lymph of ordinary 
intensity five vesicles should be raised, and that these 
should be at such distances from each other as not to 
become confluent in their advance to maturation. 

[With regard to the number of places of insertion of the virus, the 



260 QUALITY OF THE VACCINE LYMPH. 

committee of the Provinc. Med. and Surg. Association say in their 
report, " the insertion of the virus in three, or, at the most, four places, 
we believe to be quite sufficient. This," they add, "will allow one or 
two of the vesicles to be opened for the abstraction cf lymph, and the 
others to proceed in their regular and undisturbed course." 

Dr. Heirn thinks that twelve punctures are sufficient for vaccination 
of the young as well as for re-vacci nation. He says that " too many 
punctures have been followed by severe local inflammation and gangrene, 
dangerous irritative fever, convulsions, and even death itself." Among 
the Wirtemberg physicians, when only a single vesicle comes to perfec- 
tion, it is a very general practice to re-vaccinate. In this country, one 
vesicle is usually considered sufficient by practitioners, and even this is 
not always left undisturbed. 

With this latter fact in view, it is a question of interest, and worthy 
of investigation, whether varioloid is of more frequent occurrence in this 
country than in those places where the virus is inserted in so many 
points at once. It is believed that only one vesicle was aimed at by 
Jenner, when the practice was first introduced.] 

Vaccine lymph should always be used in a fluid state, 
and direct from the arm, wherever practicable, for it is 
a very delicate secretion, and very slight changes in it 
are capable of materially altering its qualities. Lymph 
which has been retained fluid for four or five days, is 
very apt to occasion that irritable vesicle which I de- 
scribed to you as the most frequent of all the anomalous 
appearances. Dr. Gulliver has lately been occupied in 
attempts to discover, by means of the microscope, what 
is the exact change which vaccine lymph undergoes by 
keeping, and which gives to it this noxious quality. 
His observations have not hitherto yielded any decisive 
results, but enough has appeared to warrant further and 
more extended inquiries. 

When lymph fresh from the arm cannot be obtained, 
other means must be had recourse to. Vaccine virus 
may be preserved fluid and effective for two or three 
days in small bottles, with projecting ground stoppers, 



PRESERVATION OF THE VACCINE LYMPH. 261 

fitted to retain the matter. It may be preserved for a 
like time in small capillary tubes having a central bulb. 
This is the mode usually adopted in France for the 
transmission of vaccine lymph to the provinces, and 
which proves very effectual ; but if you attempt in this 
manner to transmit lymph to the East or West Indies, 
you fail utterly. 

Ivory points, carefully armed from vesicles possessing 
the true characters, are very effective. They should 
be used as soon as possible, for in the lapse of time the 
thin pellicle of dried lymph is liable to be rubbed off. 
With care, however, they will retain their activity in a 
cold climate for several weeks or even months, and 
they are found to be the most certain mode of sending 
lymph to our colonies. Some practitioners prefer 
glasses to points, but they are less certain. The em- 
ployment of scabs for the propagation of cow pox was 
first recommended by Mr. Bryce, of Edinburgh, in 
1802. It is a very excellent mode of transmitting vac- 
cine matter to distant countries, but some nicety is 
required in operating with scabs, which experience alone 
can teach. 

[Mr. Cheyne recommends the use of glycerine to preserve vaccine 
lymph. He dips the sharp end of a probe in glycerine, and touches with 
it the lymph he wishes to preserve. He says its activity seems to be 
rather increased than diminished by this process, and that he always 
succeeds in developing the vaccine disease in its most complete form, 
even when lymph kept in this way for two months has been used. 
(Medical Times, March, 1850, p. 227.)] 



LECTURE XL 

PATHOLOGY AND RESULTS OF VACCINATION. 

Theory of the identity of small pox and cow pox. Arguments in support 
of that theory. Inoculation of the cow with variolous matter. Variolo- 
vaccine and retro-vaccine lymph. Objections to the theory. Equine ori- 
gin of cow pox. Doctrine of antagonism. Results of vaccination. Early 
views of Jenner concerning the permanency of vaccine influence. Notice 
of the variolous epidemics which have prevailed since the introduction of 
vaccination. Statistics of small pox as it occurs after vaccination. Num- 
ber of cases. Ages of those attacked. Per centage of mortality. Actual 
amount of vaccine security. Suggestions for increasing it. Recurrence 
to the cow for lymph. Re-vaccination. Inefficacy of these measures. 

Among the many subjects of curiosity which the theory 
of vaccination opens, the chief interest now attaches to 
the doctrine that small pox and cow pox are diseases of 
the same nature — not simply analogous diseases (which 
all must be ready to admit), but identical diseases. 
When a child is vaccinated, therefore, he has, according 
to the supporters of this, the ho?nophysic theory, received 
small pox a first time. If the child happens to take 
the ordinary casual small pox in after life, he is, accord- 
ing to the same theory, undergoing a second or recurrent 
attack of small pox. It is here assumed that cow pox 
and small pox are identical affections possessing a com- 
mon origin, and it is therefore argued that they must 
necessarily be governed, in their ultimate effects, by the 
same laws. It is a matter of considerable moment to 
determine on what grounds this opinion has been taken 
up, and to what objections it is fairly open. 

Dr. Jenner through life adhered steadily to the notion 
which he had early imbibed, that cow pox and small 



IDENTITY OF SMALL POX AND COW POX. 263 

pox were only modifications of each other. So strongly 
was this persuasion impressed upon him, that in his 
original essay he called cow pox variola vaccina. But 
he went even further. He entertained the idea, that 
cow pox was the original or parental form, which time 
and unfavorahle circumstances had converted into the 
malignant variety of small pox. Jenner believed, there- 
fore, that in giving to man cow pox, he was in reality 
giving to him small pox in its primitive and mildest 
form. Some of the followers of Jenner have adopted 
this fanciful notion. 

Diseases that mutually produce each other are clearly 
referable to a common origin. Thus swine pox and 
small pox are the same diseases ; but cow pox and small 
pox are differently circumstanced. In man, no com- 
bination of circumstances, however unfavorable, has 
ever converted cow pox into small pox ; and no care has 
ever succeeded in converting the small pox into the 
cow pox, although Dr. Adams, at one period of his life, 
flattered himself he had made approaches to that desira- 
ble consummation. 

But Dr. Baron and others have attempted to prove 
the identity of the two disorders, by reference to the 
history of epizootic maladies, and the frequent con- 
currence of a lues bovilla, or distemper in cattle, with 
variolous epidemics. Epizootics have often attracted 
public attention. In 1746 an act was passed to suppress, 
by strong preventive measures, the distemper among 
horned cattle. The fine for non-compliance was ten 
pounds. In 1757, another more stringent act for the 
same purpose w r as passed, the penalty being raised to 
fifty pounds. In 1769, a severe and fatal distemper of 
this kind ravaged England, and was considered of suffi- 



264 ARGUMENTS IN SUPPORT OF IDENTITY. 

cient importance to form part of the speech with which 
King George the Third opened the parliament, January 
9th, 1770. He recommends "this very important sub- 
ject to the immediate consideration of parliament." 
Dr. Baron, in his " Life of Jenner," (chapter 7,) labors 
diligently to prove that this bovine disorder is allied in 
many of its features to small pox. " A beast," it is said, 
" having once had this sickness, naturally or by inocu- 
lation, never has it a second time." 

A second argument brought forward to prove the 
common origin of small pox and cow pox, is deduced 
from the alleged fact, that matter taken from the cow 
laboring under the malignant epizootic has produced 
in man, by inoculation, small pox. The experiments 
performed in India, in 1833, by Messrs. Furnel and 
Brown, which appear to bear out this assertion, are 
open to many sources of fallacy. 

It has further been argued, in support of the same 
theory, that we can, by making cows breathe an atmo- 
sphere impregnated with the matter of human small pox, 
infect them with a pustular disorder attended with fever, 
the pustules so developed in the cow assuming the cha- 
racteristic appearances of cow pox, and being filled with 
a lymph exactly resembling that of the vaccine vesicle. 
These facts would be very decisive if they could be 
relied on, but no one in this country or in India has yet 
been able to verify them. 

The pathologists who support the doctrine of identity 
have lately abandoned these views, and maintain that 
the principle is fully made out by the experiment of in- 
oculating the cow with variolous matter. Such an 
attempt was first made by Gassner, in 1807, and it was 
announced that the resulting vesicle yielded a lymph, 



INOCULATION OF THE COW. 265 

which, transplanted into the human body, produced 
cow pox. The subsequent experiments of Coleman, 
Sacco, Dr. Naylor, and of others made under my own 
eye at the Small Pox Hospital in 1828, threw a 
doubt over these statements, and they were generally 
discredited. 

In 1839, Mr. Ceely, of Aylesbury, decided the ques- 
tion, by showing, in a perfectly satisfactory manner, 
that by operating upon the mucous surfaces instead of 
the more insensible corion, the cow can be made with 
facility to receive the variolous poison, which the con- 
stitution of that animal converts into vaccine. These 
important experiments were instituted under the super- 
vision of the Provincial Medical and Surgical Associa- 
tion, in whose Transactions (vols. viii. and ix.) they 
are detailed at great length. Into the details of these 
experiments it is unnecessary to enter. No doubt can 
be entertained concerning their correctness, which 
indeed the labors of some continental physicians, engaged 
nearly at the same time in the same pursuit, have abun- 
dantly corroborated. The lymph thus obtained has 
been called the variolo-vaccine, to distinguish it from 
that which is obtained from the idiopathic affection 
of the animal. 

[Dr. J. C. Martyn, residing at the time in the town of Attleborough 
(Mass.), claims as original the discovery that the cow can be variolated 
from small pox virus. On the 2d of October, 1835, he inserted small 
pox matter in one of the teats of a cow, making fourteen or fifteen 
punctures, one of which took, and was followed by a regular pustule on 
the eighth and ninth days. The matter from this, taken on the tenth 
day, he inserted in the arm of a boy, ten years old. This was followed 
by a regular vaccine vesicle, from which he vaccinated others, amounting 
in the whole to twenty-three. His experiments cost him his practice, 
and he was obliged to remove to another state. The late Dr. John D. 
Fisher, of Boston, gave him credit for these experiments. 



266 RETRO-VACCINATION. 

(For paper by Dr. Marty n, with letter from Dr. Fisher, see Boston 
Med. and Surg. Jour., Jan. 19, 1848, p. 500.)] 

M. Bousquet had previously (in 1836) determined, 
and in a measure paved the way for these experiments, 
by proving that the cow will receive the long humanized 
vaccine virus, and re-transmit it to man in a state of 
improved intensity. To this kind of lymph the name 
of retro-vaccine has been applied. These trials have 
been repeated at Aylesbury by Mr. Ceely, and the 
results of the French observers fully confirmed. 

[Dr. Pluskal has performed a series of experiments on retro-vaccina- 
tion for several years on a great variety of animals, and says that " it 
appears that it was only in those animals in whom vaccine occurs 
spontaneously, that vaccination was followed by the appearance of cha- 
racteristic vesicles, and that the experiment succeeded best in those 
animals which are most nearly allied to the ox tribe." (Dr. West's 
Report on Midwifery, &c, Brit, and For. Med. Rev., Oct., 1845.)] 

One effect of these experiments has been to refute 
Jenner's favorite notion, that the cow pox is the parent 
of small pox. So far as they go, they tend to show that 
small pox is the primary, and cow pox the secondary 
disorder. But it may reasonably be asked, do these 
experiments warrant the conclusion, that cow pox and 
small pox are identical 1 To me it appears that they 
do not. The disorders are allied (so are measles and 
scarlatina), but they are not therefore identical. The 
characters of the two are very different. Unlike small 
pox, cow pox produces no eruption, no constitutional 
disturbance ; it throws off no contagious emanations. 
It can be perpetuated from man to man in a uniform 
state of intensity ; whereas the inoculation of small pox 
produces the disorder in varying shades of severity. 
The local characters of each malady are no less strik- 



DEVELOPMENT OF THE COW POX. 267 

ingly contrasted. The variolous action goes on to 
pustulation, to the acumination of the pustule, to slough- 
ing of the corion. and implication of subjacent cellular 
membrane. The vesicle of cow pox never loses its 
umbilicated character ; no purulent matter forms ; the 
areola is circular, not irregular, like that of the inocu- 
lated small pox. 

If, then, such remarkable differences exist in the 
phenomena developed by the direct application of the 
respective poisons, we cannot be justified in reasoning 
concerning their ulterior effects on the assumed princi- 
ple that community of origin implies identity of result. 
The laws which govern the agency of the vaccine 
virus can be determined only by actual observation. 
But as pathologists have recently laid so much stress on 
the theory of the common origin of cow pox and small 
pox, let us extend our inquiries in that direction. 

The facts regarding the origin of vaccinia, so far as 
they are yet know r n to us, are these. The morbid 
secretions from the cow, which possess the singular 
properties of transplantation to the human frame, and 
of producing there a like disease, which subsequently 
protects the human body from the assaults of small pox, 
may be produced in that animal in four modes : — 

1. They are generated spontaneously in the cow. 
under certain circumstances of soil, season, and locality. 
Such diseased secretions are often met with on the teats 
of the cow soon after parturition, in the spring season 
of the year, and when the animal is feeding upon young 
grass. It was this form of the malady, arising idio- 
pathically, which Jenner chiefly studied, and from which 
all his conclusions were derived. 

2. The very same malady, developing the very same 



268 EQUINE ORIGIN OF COW POX. 

morbid secretion, is often observed to arise from con- 
tagion — that is, to originate in the application of the 
diseased secretion, thus idiopathicaily developed, to the 
teats of healthy cows, differently circumstanced, by the 
hands of the milker. I have already told you, that 
vaccine lymph from the arm of a child will, in like 
manner, excite vaccine vesicles when applied to the 
teats, or the mucous surfaces of the cow, even though 
twenty years had elapsed since that lymph had been 
humanized or assimilated to the human constitution. 

3. A like morbid product, possessed of like proper- 
ties, may be developed in the teats of the cow, by the 
application to them of matter taken from the diseased 
heels of the horse. Dr. Jenner was so deeply impressed 
with the importance of this principle in vaccine patho- 
logy, that he put it prominently forward in his very first 
paper, and even contended at that time, that the cow 
pox never appeared in cows, except when they had, 
directly, or indirectly, access to horses. Dr. Jenner 
believed that this affection of the heel of the horse was 
that commonly called by farriers the grease. Attempts 
have been made of late years to throw discredit on this 
supposed origin of vaccinia. Some have doubted the 
facts altogether. Others, as Dr. Baron and Mr. Ceely, 
aver, that the affection is not the pure grease, but a 
disorder allied to it. The name of the disease is a point 
of little importance. The experiments of Dr. Loy, Dr. 
Sacco, and many others, have satisfactorily shown not 
only that vaccine vesicles may be produced in the cow 
by matter originally supplied by the horse, but that the 
secretions from the horse's heel may be applied directly 
to the arm of the child, and will produce these vesicles 
in all respects identical with those of the true vaccine. 



VARIOLOUS ORIGIN OF COW POX. 2G9 

Di\ Baron himself acknowledges that " in his views on 
the connexion of vaccine with equine disease, once 
considered as a wild speculation, Dr. Jenner proceeded 
with his usual caution and discretion." 

[This disease in the horse has been ascertained to be a peculiar 
vesicular disorder, affecting not only the heels, but the limbs and body 
of that animal.] 

4. To these three modes, so long known, of exciting 
vaccinia in the cow, the labors of Mr. Ceely have now 
added a fourth. He has proved that the matter of 
human small pox will excite the vessels of the cow's 
teat or vaginal membrane to the production of a fluid or 
humor, identical in all its properties with that which 
arises from febrile disturbance in the cow's system, from 
contagion, and from the matter of grease, or some allied 
disorder of the horse. 

To conclude, however, from these experiments, that 
cow pox is small pox in a modified form, it should be 
shown, 1st, that the febrile disturbance of the cow is of 
the nature of variola ; and 2d, that the affection of the 
horse's heel is also variolous. Dr. Baron and Mr. Ceely, 
sensible of this, have attempted to prove both these 
points, but, in my opinion, have signally failed in each 
instance. The variolous character of the equine affec- 
tion appears to be entirely gratuitous, and I have else- 
where given my reasons for thinking that the lues 
bovilla is more nearly allied to scarlatina than to variola. 
In truth, it is neither the one nor the other, but an 
affection sui generis. 

I would rather deduce from these experiments and 
observations, the conclusion at which Mr. Creaser, of 



270 FACTS AGAINST IDENTITY. 

Bath, arrived, in January, 1801* — viz. "that a morbid 
poison applied to different animals produces, not a simi- 
lar and specific disease, but the disease to which the 
animal, from constitution and structure, is predisposed." 
Equine matter, long humanized vaccine lymph, variolous 
matter— each, when applied to the vessels of the cow, 
developes vaccinia. The constitution of the cow con- 
verts the variolous and the equine miasm into the vaccine 
miasm, in the same way as the vaccine fluid is secreted 
under several forms of feverish excitement. 

Other facts might be mentioned which militate against 
the theory of identity. If, for instance, a child is 
inoculated for small pox some days after exposure to 
casual infection, the diseases, locally and constitutionally 
excited, coalesce, and unite in producing one effect on 
the body. But if a child be vaccinated some days after 
exposure to variolous infection, the two diseases do not 
coalesce or hybridize. Each preserves its separate and 
specific character. In October, 1800, this actually hap- 
pened at the Small Pox Hospital. A child, who had 
been exposed to the infection of small pox, was vacci- 
nated. Both diseases advanced. A lancet charged 
with lymph from the vaccine vesicle produced cow pox. 
Another lancet charged with matter from a variolous 
pustule, fonned within the vaccine areola, communicated 
small pox.f If the diseases were truly identical, and of 
the same intimate nature, it is incredible that this dis- 
crepancy of result should have been observed. 



* " Greaser's Evidences of the Utility of Vaccine Inoculation. Bath, 1801." 
Page 10. 

t See ca?e of the co-existence of variola and vaccinia, recorded by Dr. Wood- 
ville, in Med. and Phys. Journal, 1801 ; vol. v. p. 8. 



DOCTRINE OF ANTAGONISM. 271 

On all these grounds I demur to the theory of 
identity, and hold that small pox and cow pox are 
antagonist affections — that cow pox, instead of being, 
as Dr. Baron maintains, of a variolous, is, in fact, of an 
ant i-variolous nature — that it alters and modifies the 
human constitution so as to render some individuals 
wholly, others partially, and for a time, unsusceptible of 
small pox. Cow pox and small pox may be viewed as 
opposing powers, striving to gain the mastery of the 
human frame, and each, under different circumstances, 
and at different times, proving successful. The con- 
clusion to which M. Bousquet {Traite de la Vaccine, 
page xvi.) has come appears to me to be the just 
one. "La vaccine," says this acute writer, " et la 
variole ne sont pas la merae chose. Mais si elles dif- 
ferent dans leur origine, dans leur principe, elles se 
suppleent merveilleusement dans leurs effects. II n'y a 
pas entre elles identite de nature, mais il y a reciprocity 
d'action." To my mind, nothing can be more satisfac- 
tory than such a conclusion. 

I have gone into this detail, because the doctrine of 
identity is now very generally received throughout this 
country, and I cannot but think it has been hastily 
adopted. The difficulties into which such a doctrine 
leads us will be made very manifest when we have 
investigated the facts regarding post-vaccine small 
pox. 

[Variola and vaccine are considered by some as merely analogous, 
and by others as" identical in their character ; while others, again, coin- 
cide with our author in believing them to be antagonistic, and others 
regard them as reciprocal in their action, or substitutes for each other. 
The fact stated by the Comm. of the Provinc. Med. and Surg. Assoc, 
and proved by statistics, that re-vaccination succeeds or otherwise on 
persons who have had small pox or cow pox, almost exactly in the same 



272 RESULTS OF VACCINATION. 

ratio, establishes, as the committee remark, a most remarkable analogy 
between these diseases. 

The committee of the French Academy on Vaccination for 1843 (M. 
Castel reporter) say, that if they are not identical in their nature, there 
is at least a great analogy between them, and give reasons for this 
opinion. 

Since the decisive experiments of Mr. Ceely, whose successful inocula- 
tion of the cow with small pox matter is now so well known, the 
advocates of the identity of the two diseases have been very much 
strengthened in their opinion, and are doubtless in the majority. 

Dr. Alex. Knox considers the question as settled, and remarks that 
the " identity supplies a powerful argument in favor of vaccination ; so 
much so," he adds, " that a conviction of the non-identity of the two 
diseases would go far to shake, in toto, our belief in the real efficacy of 
vaccination." (Lond. Jour. Med., Nov., 1850.) 

At the same time, it would seem yet to be an open question, but not 
one of sufficiently practical importance to call for more space than has 
been already devoted to it.] 

When we were engaged in tracing the early history 
of vaccination, you must have been struck with the 
extraordinary contrast between the absolute scepticism 
concerning the prophylactic virtue of cow pox which 
prevailed before the publication of Jenner's first essay, 
and the unlimited confidence reposed in it, within two 
years afterwards, in all parts of the world. A calm and 
dispassionate examination of Jenner's first essay, is cal- 
culated to awaken some surprise at this sudden conver- 
sion of men's minds. The equine origin of cow pox 
which the work begins by promulgating, was mere 
theory, which time has since greatly modified. The 
identity of small pox and cow pox, also put promi- 
nently forward, was at that time a doctrine unsupported 
by any direct experiments. The cases of successful 
result which the work recorded were few in number 
(twenty-three in all — viz. sixteen of the casual, and 
seven of the inoculated disease), and the doctrine of 



EARLY VIEWS OF JENNER. 273 

permanent security was deduced from casual causes 
alone. It is singular that in this first essay no mention 
is made of any instances in which the cow pox failed 
to afford protection in after life, though, as I stated to 
you, such occurrences had frequently been pressed upon 
Jenner's attention. It w r as not until the year 1800, 
and in his third publication, that any allusion to 
them is to be found. It ran in these words — " Some 
there are who suppose that the security from the small 
pox obtained through the cow T pox will be of a tempo- 
rary nature only. This supposition is refuted, not only 
by analogy with the habits of diseases of a similar 
nature, but by incontrovertible facts, which appear in 
great numbers against it."* In his original essay, Dr. 
Jenner does not propose the abandonment of inocula- 
tion, nor does he allude to the possible extermination of 
small pox by the general adoption of vaccination, but 
he suggests the probability of its usefulness to four 
classes of persons : — 1. to those who from family pre- 
disposition may be presumed liable to take small pox 
severely; 2. to those constitutionally predisposed 
to scrofula ; 3. to those who from peculiarity of habit 
resist small pox inoculation in after life ; 4. to those 
who may labor under some chronic ailment in which 
counter-irritation is desirable. I have shown you that 
it was an individual belonging to this fourth class, who 
was selected by Mr. Cline at this hospital, as the sub- 
ject of the first experiment in London. 

It was not long before Jenner threw off that reserve 
with respect to the powers of cow pox manifested in his 
first publication. He confidently stated that the security 

* " Continuation of Facts and Observations, by Dr. Jenner. 1800." 

18 



274 VARIOLOUS EPIDEMICS. 

afforded by cow pox was as complete and as permanent 
as that afforded by once undergoing the disease ; and 
in May, 1801, within three years from the first an- 
nouncement of his discovery, he writes thus ; — " It is 
now too manifest to admit of controversy, that the anni- 
hilation of small pox, the most dreadful scourge of the 
human species, must be the final result of this practice." 
The popular voice went fully w 7 ith Dr. Jenner in these 
pleasing, but illusory anticipations. After ten years of 
almost uninterrupted prosperity, however, the course 
of vaccination began to be slightly clouded. In the 
year 1809, Mr. Brown, of Musselburgh, published an 
inquiry into the anti-variolous power of vaccination, in 
which he broached the opinion, that its virtue dimi- 
nished as the distance from the period of vaccination 
increased. His statements, however, w r ere vague, and 
made no impression upon the public mind." 

In the year 1818-19, an epidemic small pox per- 
vaded Scotland, the first that had occurred in these 
countries since the great epidemic of 1796. During 
this epidemic, many vaccinated persons passed through 
a mild form of small pox. About this period the term 
modified small pox was introduced, and generally 
adopted. Dr. Monro, of Edinburgh, and Dr. Thomson, 
detailed the chief events of these epidemics, and though 
much discussion arose, the general confidence in vacci- 
nation was in no degree shaken. In 1824, small pox, 
after being in abeyance fourteen years, prevailed epi- 
demically in Sweden, and attacked a considerable 
number of vaccinated persons. The total mortality 
amounted to 560, of whom 103 had undergone vacci- 
nation, 69 bearing good marks, and 34 less perfect 
evidences of the vaccine process. Of the 560 deaths, 



VARIOLOUS EPIDEMICS. 275 

391 were infants and children (below the age of 15) 
— 169 were adults. In 1825, this epidemic visited 
London, a great increase in the deaths by small pox 
appeared in the bills of mortality, and many persons 
vaccinated in early life took the disease. In 1826-27, 
France suffered from an extension of the same epidemic, 
which fell with great severity on the population of 
Marseilles. Many vaccinated persons went through the 
modified disease. In 1829, the same epidemic invaded 
the north of Italy, and was particularly severe at Turin. 
In the same year, the governments of Germany, who 
always encouraged and even enforced vaccination, see- 
ing the steady advance of the disease towards them, 
took alarm; and then began that practice of re-vacci- 
nation which has formed so striking a feature in the 
medical history of the German states for the last twelve 
years. It commenced in the royal armies of Wirtem- 
berg. Then succeeded the re-vaccination of the Prus- 
sian, Danish, and Baden armies. 

In 1835, the government of Wirtemberg, satisfied 
with the results of the military trials, extended the 
plan, and ordered the re-vaccination of the entire civil 
population of the kingdom. In the meantime, however, 
small pox had made considerable ravages in the country. 
We learn from Dr. Heim's elaborate work, that in the 
five years from 1831 to 1836, there were attacked by 
small pox in Wirtemberg 1677 persons, of whom 198 
died. 1055 had been vaccinated, 75 of whom perished 
— 622 had never been vaccinated, and of them 123 
died. The population of Wirtemberg is estimated at 
rather more than a million and a half of souls 
(1,587,438). 



276 VARIOLOUS EPIDEMICS. 

Ceylon was the British colony where the government 
earliest interfered and most energetically encouraged 
the practice of vaccination. Salaried vaccinators were 
scattered over the whole island. So successful were 
their labors, that up to the beginning of 1819, it had 
often been said that the experiment of exterminating 
small pox had been made and successfully carried out 
in Ceylon. In July, 1819, however, a severe epidemic 
small pox broke out there. In 1830, a second epidemic 
overspread the island — in 1833, a third, and in 1836 a 
fourth. In these four epidemics, 12,557 persons were 
attacked, of whom 4090 died, being at the rate of 
thirty-three per cent, or one out of every three, — prov- 
ing that small pox had lost nothing of its malignity 
during its period of quiescence. 

It is true that the largest proportion of the persons 
so attacked had never been vaccinated, but in each of 
the epidemics a certain number of vaccinated persons 
took small pox. The proportion of the vaccinated to 
the unprotected varied. In the third epidemic, out of 
a total of 460 attacked, 341 represented themselves as 
vaccinated. 

Denmark has undergone several visitations of epi- 
demic small pox ; yet in no country in Europe has 
more attention been paid to the practice of vaccination, 
both as respects the numbers submitted to the process, 
and the purity of tbe lymph employed. 

The first was in 1824, the second in 1826, the third 
in 1829. Copenhagen suffered also in the years 1833 
and 1835. 

England experienced the second epidemic visitation 
of this century in the year 1838, and again many vac- 



STATISTICS OF SMALL POX. 277 

cinated persons (or persons believing themselves to 
have been vaccinated, and trusting to it as their 
security) suffered attacks of the prevailing malady. 

This epidemic commenced in the summer of 1837, 
and did not finally terminate till December, 1839. The 
total deaths throughout England and Wales during 
that period (two years and a half) by small pox, 
amounted to 30,819, or an average of 12,200 deaths 
per annum. Calculating that the rate of mortality ruled 
about twenty or twenty-five per cent, it follows that in 
those thirty months there occurred in England and Wales 
not fewer than one hundred and fifty-four thousand 
cases of small pox. In 1844-45, another severe epi- 
demic invaded London, commencing April 21, 1844, 
and terminating May 25, 1845. Nearly at the same 
period, small pox appeared as an epidemic at Calcutta. 

After this imperfect sketch of the reappearance of 
small pox both in Europe and Asia, since the lull which 
succeeded the first introduction of vaccination, I shall 
proceed to state to you the results which statistical 
researches have given, as to the relative numbers and 
ages of the vaccinated who have been attacked by 
small pox, and the ratio at which small pox succeeding 
to vaccination has proved fatal in this and other 
countries. 

I shall begin by stating the results of the experience 
at the Small Pox Hospital, and shall then contrast them 
with the recorded experience of other countries and 
other establishments. 

The following table was presented by me to a com- 
mittee of the House of Commons which sat, in 1832, 
to consider the expediency of continuing the Vaccine 
Board. 



278 



STATISTICS OF SMALL POX 



No. 1. — Table exhibiting the Admissions and Deaths at the Small Pox 
Hospital in the Seven Years from 1826 to 1832 inclusive. 









Numbers having the 




Total Number treated 


Small Pox at variable 


YEARS. 


at the Hospital. 


periods after Vac- 








cination. 


Admissions. 


Deaths. 


Admissions. 


Deaths. 


1826 


168 


52 


63 


4 


1827 


305 


85 


105 


1 


1828 


202 


67 


71 


3 


1829 


328 


103 


109 


7 


1830 


259 


76 


84 


7 


1831 


193 


53 


66 


6 


1832 
Total . . 


330 


98 


121 


12 


1785 


534 


619 


40 



With this we may compare the results of the suc- 
ceeding seven years at the Small Pox Hospital, which 
will be seen in the following table : — 

No. 2. — Table exhibiting the Admissions and Deaths at the Small Pox 
Hospital in the Seven Years from 1833 to 1839 inclusive. 







Numbers having the 


TEARS. 


Total Number treated 
at the Hospital. 


Small Pox at variable 
periods after Vac- 
cination. 


Admissions. 


Deaths. 


Admissions. 


Deaths. 


1833 


24'2 


50 


89 


4 


1834 


165 


23 


63 


3 


1835 


401 


89 


144 


A 


1836 


329 


84 


128 


10 


1837 


251 


46 


95 


1 


1838 


712 


188 


298 


31 


1839 
Total . . 


155 


27 


83 


4 


2255 


507 


900 


60 



Also the results of the next four years at the same 
hospital : — 



AFTER VACCINATION. 



279 



"No. 3. — Table exhibiting the admissions and deaths at the Small Pox 
Hospital in the seven years from 1840 to 1846 inclusive. 



YEARS. 


Total numbers treated in the Hospital 


Numbers having 


Rate 
per cent. 

of 
mortality. 


Total 
Admitted. 


Not hav- 
ing Small 


Total Small Pox 
Patients. 


periods after vacci- 
nation. 
















Admitted. 


Died. 


Admitted. 


Died. 




1840 


327 


11 


316 


95 


120 


8 




1841 


357 


15 


342 


74 


151 


10 




1842 


155 


14 


141 


34 


62 


4 




1843 


160 


11 


149 


27 


69 







1844 


647 


4 


643 


151 


312 


24 




1845 


384 


16 


368 


79 


217 


13 




1846 


152 


5 


147 


29 


80 


5 




7 years. 


2182 


76 


2106 


489 


1011 


64 


6J 



From the preceding tables it appears that the num- 
bers admitted after vaccination, had increased in the 
second septennial period from 34 to 40 per cent, of the 
total admissions, and in the third septennial period to 49 
per cent, the rate of mortality remaining the same. 

The sum total of the three septennial periods affords 
the following gross results : — 



Total admissions into the Small Pox Hospital during 21 
years, . . . _ 

Total deaths in the same period, . 

Total cases of small pox after vaccination in 21 years, . 

Total deaths among the cases of small pox after vaccina- 
tion in 21 years, 

General rate of mortality, 

Rate of mortality after vaccination, . 




Among the most interesting documents which I have 
obtained, bearing upon the subjects now under consider- 
ation, are the following, which exhibit the amount and 



280 



STATISTICS OF SMALL POX 



character of the cases of variola succeeding vaccination 
which occurred in the British army, on home and for- 
eign service, during the five years from 1834 to 1838 
inclusive. I must premise that the strength of the army 
during that period (including men, women, and chil- 
dren), was very uniform, averaging about 105,000. 
The regulations of the army require, and the careful 
superintendence of the medical officers ensures, that 
every individual of that force (not having previously 
undergone small pox) had been effectively vaccinated. 
There is here, therefore, no room for dispute as to the 
reality of the alleged prior vaccination — a difficulty 
which meets us in almost every other case. 

A. Table showing the total number of cases of S?nall Pox after vaccina- 
tion, with the mortality, which occurred in the British Army, on home 
and foreign service, during the five years from 1834 to 1838 inclusive, 
distinguishing the years : — 



YEARS. 


Home Service. 


Foreign Service. 


I 

Total 
Cases. 


Total 
Deaths. 


Rate of 
mortality 
per cent. 


Ad- 
missions. 


Deaths. 


Ad- 
missions. 


Deaths. 


1834 
1835 
1836 
1837 
1838 


42 

63 
106 
163 

231 


3 
3 

7 
25 

27 


23 

50 

10 

200 

137 


3 

8 

1 

21 

24 


65 
113 
116 
363 
368 


6 
11 

8 
46 
51 


92 

9-7 

6-9 

12-6 

13-8 


Total 


605 


65 


420 


57 


1025 


122 


11-9 



Average strength of the army on home service, . . 36,000 
" " " foreign service, . 69,000 



Total, 



105,000. 



B. Table exhibiting the comparative severity of small pox, as it occurred 
in the British Army, among the vaccinated, on home and foreign 



AFTER VACCINATION. 



281 



service, during the Jive years from 1834 to 1838 inclusive, with the 
mortality. 



CHARACTER OF THE 
DISEASE. 


Home Service. 


Foreign Service. 


Total. 


Ad- 
missions. 


Deaths. 


mislTons.j Deaths " 


Ad- 
missions. 


Deaths. 


Distinct, . . 
Confluent, . . 
Modified, . . 


139 

208 
258 


4 
60 

1 


167 

99 

154 


4 

51 

2 


306 
307 

412 


8 

111 

3 


Total, . . . 


605 


65 


420 


57 


1025 122 



The next table shows the modifying effects of vacci- 
nation whenever the variolous miasm spreads epidemi- 
cally in a population extensively vaccinated. Such is 
the population of Copenhagen. 

Table exhibiting the Amount and Mortality by Small Pox in the well 
vaccinated population of Copenhagen, from 1824 to 1835. 



1st Epidemic 
2d ditto 
3d ditto 
4th ditto 
5 th ditto 


Period occupied by each 
Epidemic. 


Total 
Attacked. 


Total 
Deaths. 


After 
Vaccination. 


Total 
Attacked. 


Total 
Died. 


Jan. 22, 1824 to Feb. 28, 1825 
Sept. 1825 to Augt. 1826 
March 1828 to July 1830 
Augt. 1832 to Dec. 1834 
May 15 to Dec. 31, 1835. . . 

Total . 


412 

623 

562 

1045 

1197 


40 
39 
28 
45 
106 


257 
438 
457 
898 
1043 


3 

2 

4 

10 

47 


3839 


258 


3093 


66 



These statements and tables are amply sufficient to 
show how large a proportion of those who, in Europe, 
at the present time, contract small pox, have undergone 
vaccination in early life. They cannot be perused 
without the conviction, that some material error had 
crept into the views originally entertained regarding 
the power and capabilities of the vaccine inoculation, 



282 



AGES OF PERSONS ATTACKED 



If small pox can invade so large a proportion of a well 
vaccinated population, as the last table exhibits, it is 
obvious, that all idea of banishing that disease from the 
earth is vain and illusory. It is equally manifest, that 
any attempt to institute a parallel between cases of 
small pox after vaccination, and cases of secondary or 
recurrent small pox, must fail. The most credulous on 
this point may search far and wide, before he finds in 
the records of the last century any counterpart to the 
facts which these five Danish epidemics display. 

The interval between the primary vaccination and 
the attack of small pox fluctuated in most of the pre- 
ceding instances between seven and thirty years. By 
far the larger proportion of the cases consisted of adults 
in the vigor of life. The following table exhibits the 
ages of those who were admitted into the Small Pox 
Hospital, having small pox after vaccination, during the 
epidemic of 1838. 

Ages of those admitted into the Small Pox Hospital, in 1838, having 
Small Pox after Vaccination. 



AGES. 


Admissions. 


Deaths. 


Under 5 years of age 
From 5 to 9 inclusive 

" 10 to 14 

" 15 to 19 

" 20 to 24 

" 25 to 30 

" 31 to 35 

Above 35 years of age 

Total . 




5 

25 

90 

106 

55 

13 

4 





6 
16 
8 
1 



298 


31 



From this it will be seen that between the ages of 
twenty and twenty-five, the disposition in the vaccinated 
to take small pox is at its maximum. 



BY POST-VACCINE SMALL POX. 



283 



We may compare these results with those derived 
from the experience of Continental physicians. The 
writings of Dr. Heim, of Ludwigsburg, and Dr. Mohl, 
of Copenhagen, furnish us with the required details. 

Table exhibiting the relative Ages of Persons attacked by Small Pox 
after Vaccination in Wirtemberg and Denmark. 



AGES. 


Wirtemberg. 
Br. Heim. 


Denmark. 
Dr. Mohl. 


Between 1 and 5 years, inclusive, . 
" 6 and 10 . 
" 11 and 15 . 
" 16 and 20 . 
" 21 and 25 . 
" 26 and 30 . 
" 31 and 35 . 

Total 


40 
68 
186 
275 
239 
172 
75 


14 
102 
173 

187 

156 

19 

2 


1055 


653 



These tables correspond so closely with each other, 
and with the experience of the Small Pox Hospital 
already given, that you may rest assured they indicate 
some law of the animal economy. In each instance, 
you perceive, the maximum of cases occurs at the 
period which immediately follows puberty. It is there- 
fore rendered more than probable that some modifica- 
tion of the system takes place at that eventful epoch of 
human life which lessens the protective power that 
vaccination had previously exerted. I have already 
made you acquainted with the fact, that in very early 
times an impression prevailed that the protective power 
of cow pox did deteriorate in the course of time, and 
that Jenner was very unwilling to give credit to it. It 
is a matter of general notoriety that small pox is very 
seldom taken by vaccinated children who are under 



284 PROTECTIVE POWER OF COW POX. 

the age of eight years. In the course of a long expe- 
rience at the Small Pox Hospital, I have never seen 
more than three or four instances of such an occur- 
rence. The protective power of cow pox may there- 
fore, for all practical purposes, be considered as complete 
for that period ; but we are compelled to confess that 
later in life it diminishes in a certain proportion of 
cases. What the exact proportion is, never has been 
ascertained, and, for very obvious reasons, never can be 
known or even guessed at. 

But though this be impossible, there seems no reason 
why we should not attempt to ascertain the laws which 
affect and limit that power of resistance to the vario- 
lous virus which cow pox displays in so many instances^ 
and so remarkably in infantile life. I have mentioned 
puberty as a disturbing cause. I have no doubt that 
others exist, of equal, perhaps of superior efficacy. 
Among them may be mentioned change of climate, 
which appears to have a very marked influence, suffi- 
cient to induce us to recommend the re- vaccination of 
all young people going to or returning from India. A 
severe fever, in like manner, may so alter and modify 
the general mass of fluids as to open a door to the 
reception of the variolous effluvium. Importance should 
be attached also to the epidemic constitution of the 
season. It is certain that persons who under common 
circumstances have, through the agency of the cow 
pox, resisted the variolous miasm, succumb to it under 
epidemic visitation. To pursue these speculations 
would lead us out of our course. I recommend them, 
however, to your future study, from a firm conviction 
that a knowledge of the laws which limit the powers 



RATE OF MORTALITY. 



285 



of cow pox will improve pathology far more than a 
blind adherence to the doctrine of its unvarying pro- 
phylactic virtue. 

The preceding tables, while they certainly counte- 
nance the notion of diminished vaccine energy through 
the medium of those changes which time effects in the 
frame, prove at the same time, most incontestably, that 
a portion of virtue still clings about the system sufficient 
to preserve life, though not to exhaust susceptibility. 
To determine with accuracy the average ratio of mor- 
tality which obtains when small pox invades those who 
have been well vaccinated, is a point which the statisti- 
cal records of the last twenty years teach us with 
considerable precision. You will remember that small 
pox in former times (and among the unprotected in 
recent times) proved fatal at the rate of twenty-five, or 
from that to thirty-three per cent, (one out of four, or 
one out of three). 

Table showing the Rate of Mortality by Small Pox after Vaccination 
at different periods and in different parts of the world. 



LOCALITY. 


Number of 
Cases. 


Deaths. 


Rate of 
Mortality 
per cent. 


Small Pox Hospital, ) lg26 lg32 
London, j 
Ditto .... 1833 to 1839 
Ditto . . . . 1840 to 1846 

Total at ditto 1826 to 1846 

British Army. . . 1834 to 1838 
Copenhagen . . . 1824 to 1835 
Wirtemberg . . . 1831 to 1836 
Vienna .... 1834 
Ceylon, Epidemic of 1830 

Ditto .... 1833 to 1834 

Total . . . 


619 

900 
1011 


40 

60 
64 


7 

7 

H 

7 

12 

2 

7 

8 

13 

7 


2530 

1025 

3093 

1055 

200 

260 

341 


164 

122 
66 
75 
16 
34 
23 


8504 


500 


6 



286 



AMOUNT OF VACCINE SECURITY. 



The previous table, compiled from various sources, 
will show how great is the diminution in the ordinary 
rate of mortality by small pox when vaccination has 
preceded. It will be seen that the average rate is 
then six per cent, the maximum being thirteen and 
the minimum two. 

The result of these statistical investigations may be 
stated to you in a few words. Small pox in the un- 
vaccinated is five times more fatal than it is to those 
who have previously undergone vaccination. The fol- 
lowing table, carefully drawn up from the records of the 
Small Pox Hospital for the year 1841, shows you how 
this is effected. It is an analysis of the several cases 
admitted in that year, having small pox after vaccina- 
tion. It will be seen that nearly two thirds of the 
cases (or 60 per cent.) received the disease in a modi- 
fied form. The remainder (40 per cent.) received it 
in a normal form, but in variable degrees of intensity, 
the mortality among them following the ordinary law. 

Analysis of 151 cases of Small Pox succeeding Vaccination, which 
occurred at the Small Pox Hospital in 1841. 



Normal . . 56 \ 

Abnormal, or ) Q ^ 
modified ) 


Confluent 

Semi-confluent 

Distinct, regular .... 
Confluent modified . . . 
Semi-confluent modified . . 
Varicelloid, or distinct ) 
modified ) 

Total .... 


Ad- 
missions. 


Deaths. 


25 

19 

12 
18 
19 

58 


8 

1 

1 




151 


10 



Deducting the two deaths among the milder cases, 
which were the results of superadded disease, there 



FREQUENT RENEWAL OF LYMPH. 287 

remain eight deaths. Now supposing that these 15 J 
persons had never been vaccinated, the mortality would 
have been at least five times eight, or forty, and might, 
under unfavorable circumstances, have reached fifty. 
Such appears to be the actual amount of the protection 
which vaccination affords, and with it, such as it is, we 
must, I believe, rest satisfied. My firm persuasion is, 
that no additional precautions on the part of vaccina- 
tors, and no alteration in the kind of lymph employed, 
will have the slightest effect on the general results. 
But the world are not so easily persuaded to rest upon 
their oars. They have been taught to believe that 
vaccination was an almost certain preventive of small 
pox, and they are loath to see it shorn of its original 
splendor. A restlessness and dissatisfaction, indeed, in 
regard to the amount of vaccine protection, have been 
perceptible throughout Europe for many years, and 
two expedients have been largely practised, with the 
view of increasing the security of the vaccinated. One 
of these is the employment of lymph recently derived 
from the cow ; the other is re-vaccination. A few 
observations on each of these topics will conclude my 
account of cow pox. 

[For remarks on the mortality of small pox after vaccination, see 
Appendix L.] 

An impression that vaccine virus decays in power, 
in proportion to the number of times that it makes the 
circuit of the human body, has long prevailed. In all 
parts of the Continent, and recently in England also, it 
has led to the frequent trials of lymph fresh from the 
cow. Jenner did not object to occasional renewals of 
the stock of lymph, but it does not appear that he ever 
acknowledged deterioration of the virus by use as a 



288 FREQUENT RENEWAL OF LYMPH. 

common occurrence, or as a source of failure. In 
1829, the invasion of epidemic small pox induced the 
Sardinian government to try a variety of new stocks of 
lymph. We are informed by Dr. Griva, chief of the 
vaccine establishment at Turin, that no perceptible 
difference was to be traced between the aspect and 
progress of the old and of the new lymph. In Wir- 
temberg, between 1831 and 1836, forty new varieties 
of lymph were tried, but without any obvious advan- 
tages. In other parts of Germany, the same trials were 
made. In France, a new variety of lymph, obtained 
from the dairies of Passy, near Paris, was brought into 
use by M. Bousquet in 1836, and it certainly proved 
much more energetic in its 'primary effects than that 
which had previously been employed. About the same 
period, we changed our stock of lymph at the Small 
Pox Hospital, and with decided advantage. There are 
occasions, therefore, when I should be disposed to 
recommend the measure, but it is not lightly to be 
resorted to. Heim calculates that three fourths of the 
inoculations made with lymph direct from the cow fail 
altogether of effect. When they do take effect, it often 
happens that severe local inflammation is excited, pro- 
ducing irritable sores and glandular swellings. Nor are 
w T e at all sure that the ultimate effect, the security of 
the patient in after life, will be sensibly augmented. 

[Some difference of opinion seems to exist as to the necessity of 
resorting to the cow for supplies of fresh lymph. The Committee of 
the Provincial Med. and Surg. Association conclude that it does not 
necessarily become deteriorated, though it may have passed through a 
great number of subjects, and have been used for a great number of 
years. 

M. Fiard, however, infers from the result of his experiments with the 
vaccine matter of 1836 and 1844, that it has decreased in efficacy, and 



RE-VACCINATION. 289 

hence concludes, that it should be procured fresh from the cow every 
five or six years. (L'Abeille M6d., Nov., 1844, p. 262.) 

M. Castel says (Report of Committee on Vaccination of French 
Academy for 1843), that whatever may be the opinion of practitioners 
on this controverted question, it is an act of prudence to permit no 
opportunity to escape of renewing the vaccine virus. 

Mr. Steinbrenner says ( Traiti de la Vaccine, Paris, 1846) that " vaccine 
virus does undergo a positive deterioration by transmission through suc- 
cessive individuals, and that it is therefore desirable to obtain fresh lymph 
from the cow frequently, which may be done by taking it annually." 

The Committee of the French Academy which reported in 1845, 
also recommended, as a prudential measure, the frequent renewal of 
vaccine lymph, and resorting to the cow for this purpose.] 

And now as touching re-vaccination. It is believed 
by many that vaccine protection may be renewed, as 
we renew the lease of a house, every seven, fourteen, 
and twenty-one years. By the physicians of Germany, 
re-vaccination has been held up as a measure scarcely 
less important in its effects, nor less widely applicable, 
than primary vaccination. Tn France, on the other 
hand, the repetition of the vaccine process has been 
disparaged. A commission, expressly nominated to 
investigate the matter, comprising some of the most 
talented men in Paris, reported against re- vaccination. 

The question is not easily decided for want of data, 
which, in the very nature of things, can never be sup- 
plied so as to insure a satisfactory result. Happily, 
there is no occasion to press the cause to judgment. 
The operation, except in a few rare instances, is pro- 
ductive only of slight and temporary inconvenience, 
and may safely be recommended. 

If the resulting vesicles prove good, and the course 
of the disorder normal, you have good grounds for 
congratulating the patient upon the success of your 
measure. In the larger number of instances, however, 

19 



290 RE-VACCINATION. 

this will not happen. The vesicles will be small, the 
areola irregular, and the benefit scarcely appreciable. 

In a few cases, the process of re- vaccination occa- 
sions considerable local distress, and some amount of 
constitutional disturbance. I have seen extensive ery- 
thema of the arm follow re- vaccination. Delicate 
young women of scrofulous habit of body are liable to 
suffer in this way. It is the chief drawback to the 
general adoption of re-vaccination in adult life. 

The imperfect aid afforded by re-vaccination suggests 
the question whether, in adult inoculation (between 
the ages of twelve and twenty), we might not find a 
better mode of testing and improving the security of 
the vaccinated. Small pox, taken casually after vacci- 
nation, proves fatal, as we have seen, at the rate of 
seven per cent. Inoculated small pox proved fatal, in 
former times, at the rate of only one fifth per cent., or 
one in five hundred. As regards the extension of small 
pox from the practice of inoculation, no real danger 
need be apprehended. The experience of ten years in 
England has amply demonstrated that the diffusion of 
small pox is wholly independent of such artificial pro- 
pagation. Small pox has been as general in England 
since inoculation was abolished as it was previously. 
But it is as yet little known, that small pox may be 
received into and pass through the system without pro- 
ducing either fever or eruption. I inoculated three of 
my own children at the respective ages of twelve, 
thirteen, and fourteen, after successful vaccination in 
infancy, and the result was as follows : — In two, local 
affection without any fever or eruption. In the third 
case, local affection without fever, but with papular 
eruption on the seventh day, not advancing to vesicles. 



RE-VACCINATION. 291 

I firmly believe that these children are now, and will 
remain through life, unsusceptible of small pox. The 
advantages derivable from such a course of procedure 
are these : — If the child's constitution be under the full 
vaccine influence, no effect will follow. If the vaccine 
influence be subsiding or altogether lost, then the small 
pox will be taken at the period of life (puberty) most 
favorable for safety, instead of being received (as too 
often happens under the present system) under circum- 
stances the most unfavorable, — for instance, by mothers 
at the period of parturition, by young women on the 
eve of marriage, or by young men at a distance from 
their friends. The state of the law in England pro- 
hibits the practice here ; but I hope it will be tried in 
other countries, where the judgments of medical men 
are less fettered. 

[For remarks on Re-vaccination, see Appendix M.] 



LECTURE XII. 

VESICULAR ERUPTIONS. 

Early history of varicella or chicken pox. Detail of its symptoms, and 
progress of the eruption. Question of its identity with variola con- 
sidered. Diagnostic characters of varicella vera and of variola varicelloides. 
Question of the inoculation of chicken pox considered. Of herpes. 
Characters of herpetic eruption. Varieties of herpetic eruption. Herpes 
zoster, circinatus, labialis, iris. Sources of herpes. Treatment. Miliaria. 
Early history of miliary fever and eruption. Appearances of miliary 
eruption. Causes of miliary eruption. Theory of miliary eruption. 
Treatment. Of the pemphigus and pompholyx. Their treatment. Their 
principal varieties — the chronic, acute, and gangrenous or infantile pem- 
phigus. 

VARICELLA. 

The very mildest form in which disease ever shows 
itself, involving neither risk to life nor any consequences 
of serious import, is the complaint known familiarly by 
the name of chicken pox, and to systematic writers, by 
that of varicella. Some might consider it unworthy of 
occupying attention in a course of lectures where there 
is hardly time for investigating fully the more serious 
disorders of the body. But something may be learned 
from the study of nature under all her aspects, the 
mildest as well as the gravest, and we shall find varicella 
to afford some lessons of practical utility. 

From the earliest periods at which small pox was 
noticed, physicians have remarked a mild form of erup- 
tion, resembling it in some respects. Rhazes describes 
a mild or spurious eruption which gave no protection 
against small pox when it occurred epidemically ; 
doubtless, this was varicella. 



HISTORY OF VARICELLA. 293 

The first acknowledged author on varicella is Ingras- 
sias, a Sicilian physician, who, in 1553, published at 
Naples a work entitled, " De Tumoribus contra Natu- 
ram," — " On Preternatural Swellings/' — in which he 
gives a very distinct sketch of varicelloid eruption. He 
was followed, about forty years afterwards, by Vidus 
Vidius, an anatomist and physician, who wrote an 
" Ars Medicinalis," in which he gives an improved ver- 
sion of Jngrassias. He describes varicella under the 
title of a third species of small pox, the two first being 
variola vera and rubeola. To this he gives the name 
of chrystalli, or variolar chrystallinse, by which name it 
was long known. By the Italians it was early called 
ravaglione. Sydenham passes it over without notice. 
Riverius, in 1646, describes it accurately.* Morton, 
still later in the century, mentions this disorder under 
the title of variolar admodum benignae, and states that 
it was vulgarly known in this country under the name of 
chicken pox. This is the first mention I can find of 
the term chicken pox (1694). In the expressions, 
chicken pox, swine pox, and cow pox, popularly 
applied to three varieties of mild eruptive ailment in 
man, it is curious to trace the latent doctrine of animal 
miasm. Morton and all the authors of that oeriod 
concurred in considering chicken pox as the mildest 
possible form of small pox. 

Nothing worthy of observation concerning varicella 



* The description of Riverius is so terse and accurate, that I am tempted to 
give it in his own words : — " Est et tertium pustularum genus, pueris famiiiare et 
variolis simile quoad magnituclinem et figuram ; sed in eo ab iis clistinguitur quod 
variolae cum rubore et inflammatione appareant. Hae vero albas sunt et veluti 
vesiculse seroso humore repletae, qua? intra triduum disrumpuntur, et exsiccantur. 
nullumque solent afferre periculum, et plerumque sine febri erumpunt. Id pustu- 
larum genus a nostratibus foeminis la verolette nominari solet." 



294 HISTORY OF VARICELLA. 

occurs in medical history until the year 1767, when Dr. 
Heberben, in the first volume of the Transactions, pub- 
lished by the Royal College of Physicians in London, 
entered fully into the theory and diagnosis of varicella. 
He adopted the notion, hitherto unavowed by any 
medical author, that variola and varicella are different 
diseases. He brings forward very strong arguments in 
favor of this doctrine. His paper is long, and appa- 
rently drawn up with great care and attention. But 
Heberden falls into many errors, and was obviously 
ignorant of some essential facts bearing upon the patho- 
logy of varicella. He merits our applause, however, 
for having first distinguished varicella as the offspring 
of a specific poison. The strange thing is that, with 
this impression so strong on his mind, he should still 
have called the disease variolce pusillce. It had been 
named varicella three years before, by Vogel, in Ger- 
many. The term varicella does not occur in Sauvages' 
" Nosology," published in 1768. His synonyms are 
" water pock, petite verole volante, verolette, varioke 
lymphatics, variolar volaticre." We may be sure from 
this that the term varicella did not come into general 
use until after 1770. 

Heberden's memoir on chicken pox was long con- 
sidered as the standard work on the disease. The 
principal authors on varicella in the present century are, 
Frank, of Vienna, who wrote on it in 3 805, under the 
title of Pemphigus Variolodes Vesiculosus ; Will an, in 
1806, who has a chapter devoted to varicella in his 
work on " Vaccine Inoculation;" Dr. Keim, of Berlin, 
1809, a notice of whose work is to be found in Cross's 
"Account of the Variolous Epidemic of Norwich;" 
Dr. Mohl, of Copenhagen (1817), whose treatise is 



DETAIL OF ITS SYMPTOMS. 295 

entitled " De Varioloidibus et Varicellis ;" and lastly, 
Dr. Thomson, of Edinburgh, who wrote on it in 1820, 
and revived the exploded doctrine of its identity with 
small pox. 

And now I must give you a brief description of this 
disease, the true, vesicular, lymphatic varicella — the 
bastard, flying, lymphatic, crystalline, or imperfect 
variola of some authors. The definition of varicella is 
as follows : — " A slight disorder, the offspring of a spe- 
cific miasm, which, without initiatory fever, throws out 
an eruption of vesicles, sometimes distinct, sometimes 
confluent, which maturate in three days, and desiccate 
into granular scabs, which speedily fall off. Little or 
no fever accompanies the maturative stage, and no 
secondary fever follows. The disorder chiefly prevails 
among children, and occurs but once in life." 

Varicella has a very short incubation, not exceeding, 
as I believe, four days, certainly less than a week. Dr. 
Heberden, in his Commentaries, mentions the case of 
a lady whose two boys had varicella. On the eighth 
or ninth day from the maturity of the vesicles, the 
mother sickened for the same malady. He then 
inquires whether this is the usual period of incubation. 
This incubative period is always, so far as I have seen, 
silent, and so say Heberden, Plenck, and Bryce ; but 
Dr. Willan, who is entitled to attention, says there are 
often present, for one, two, or three days prior to the 
eruption of varicella, languor, somnolency, a furred 
tongue, a hot skin, a quick pulse, with some sore throat 
and rheumatic pains. I cannot reconcile these state- 
ments of Willan with the results of my own expe- 
rience. 

[In an epidemic of varicella at the Hospital Necker (Paris) in 



296 PROGRESS OF THE ERUPTION 

1843-44, accurately described by M. Delpech, he fixed the incubative 
period at twelve days.] 

The first thing I ever observe in varicella is the 
eruption of vesicles, of the size of a split pea, being 
simple elevations of the cuticle, or minute blisters, pre- 
senting the appearance of the skin having been exposed 
to a shower of boiling water. The parts chiefly occu- 
pied by the eruption are the back and scalp. The face 
is not so universally the seat of eruption, as happens in 
small pox. Nevertheless, at times, the face is exten- 
sively occupied. The vesicles vary in shape. Dr. 
Willan, who loved minuteness, wishes to distinguish 
three kinds — the lenticular, conoidal, and globate. I 
cannot see these distinctions myself, and therefore I 
will not attempt to teach them to you. The vesicles 
are surrounded by a superficial and narrow areola. 
They appear in successive crops for two or three days. 
While the new vesicles are forming, the old ones shrivel 
and dry up. 

[Careful examination will show that the vesicles in varicella do pre- 
sent these three varieties of form pointed out by Dr. Willan, and 
admitted by later writers ; but they may all be found in the same 
individual at the same time, and therefore the distinction is of no impor- 
tance in a practical point of view. 

The vesicles are sometimes preceded by small, pale, rose-colored 
spots, with little or no elevation, the color of which disappears under 
pressure of the finger, which are soon followed by elevations of the 
epidermis. The occurrence of such spots has been denied by some, 
but they have been pointed out by Halle, and were particularly noticed 
by M. Trousseau during an epidemic of varicella at the Hospital JNecker 
(Paris), in 1843 and 1844. 

Sometimes, also, the vesicles enlarge to such an extent as to resem- 
ble true bullae of pemphigus. "We have known the bullae reach the 
size of half a dollar, and even of a dollar ; and in one case, the excoria- 
tions left by several bullae which had been rubbed, extended for five 



VARICELLA CONTRASTED WITH VARIOLA. 297 

or six inches on the upper part of the back, in an infant eight months 
and a half old.] 

On puncturing the vesicles, a clear lymph, scarcely at 
all mucilaginous, escapes, and the cuticle falls to the 
level of the surrounding skin. There is no tumor, no 
varus. If the vesicle remain unbroken for twenty-four 
hours, the contained fluid becomes slightly opaque. 
They are very itchy, and when rubbed, a degree of 
superficial inflammation may succeed, sufficient to con- 
vert the lymph into an imperfect pus. The scabs of 
varicella are very small, and as the lymph wants a 
mucilaginous quality, they are granular. The desicca- 
tion is very rapid, and in six days the complaint com- 
pletes the whole circle of its phases. 

I once saw varicelloid vesicles occupying the throat. 
The case was more severe than the common type of 
varicella, and was accompanied by a light febricula. 
Generally speaking, no constitutional symptoms of any 
importance are present. The tongue is clean, and the 
pulse unaffected. The aspect of countenance betrays 
neither languor nor feverishness. The appetite is good, 
and the sleep undisturbed. The complaint often shows 
itself in schools, and runs through all the young mem- 
bers of a family. It is manifestly both contagious and 
epidemic. 

Now, can this be a form of variola ? Observe the 
marked differences between the two disorders. Vari- 
cella has not the incubative period of variola. It has 
not the character of variolous eruption. Children take 
it almost exclusively. I do not say that adults never 
take it. I have seen a few adult females attacked by it, 
but it is a rare occurrence. This is not like variola. 
But far and above all, it is taken indiscriminately by 



298 VARICELLA CONTRASTED WITH VARIOLA. 

those who have and those who have not been vacci- 
nated. Its course is not in the slightest degree altered 
by previously undergoing vaccination. It is now nearly 
always taken after vaccination. Whether it was taken 
equally after inoculation of small pox I cannot tell you 
from my own experience, but I have the authority of 
Sir Henry Halford for saying that it was ; and there 
are few physicians now besides himself who can be 
appealed to on such a point. These general conside- 
rations are of themselves sufficient to decide the ques- 
tion of non-identitv. 

But if we examine the subject still more closely, we 
find that the organization of the varicelloid vesicle dif- 
fers from that of the variolous. I acknowledge to have 
seen vesicles on the face, of a true varicelloid origin, 
which in aspect and arrangement closely resembled 
those of genuine small pox, but in the greater number 
of cases, especially when the vesicles of the trunk and 
extremities are examined, there is no umbilication, no 
central depression, no division into cells, no slough. 
There are simply partial elevations of cuticle, of irregu- 
lar and undetermined arrangement. Here we see no 
groupings into threes and fives, no crescentic or circular 
figures formed. Everything in varicella is hurried for- 
ward — the incubation, the eruption, the desiccation. 

These things seem so clear, that you may naturally 
be tempted to ask — how did the notion of identity ever 
originate 1 A reply to this question will lead us still 
further into the consideration of diagnosis and general 
pathology. There is a disease which resembles vari- 
cella in its mildness, which really does arise from the 
variolous poison ; and physicians, in former times, look- 
ing only to the general, and neglecting the minute 



DIAGNOSIS OF VARICELLA AND VARIOLA. 299 

anatomical characters of the eruption, have thought 
proper to confound the two diseases. By way of dis- 
tinction, we will call the one varicella vera ; the other, 
variola varicelloides. I do not say that mistakes can 
always be avoided. During the year 1842, a child 
was admitted into the Small Pox Hospital, having 
the incubative symptoms of variola, and the local 
symptoms of varicella. I remain doubtful about this 
case. Nothing but inoculation with small pox could 
clear up the difficulty. In most cases, however, the 
diagnosis is clear enough. Let me enumerate the chief 
features of each complaint. 

In the true lymphatic varicella, there is no premoni- 
tory fever. In the variola varicelloides, there are at 
least forty-eight hours of preceding febrile disturbance. 
In the varicella vera, there are no hard vari or tuber- 
cles. In the varicelloid form of variola, tuberculous 
elevations of the skin are distinctly perceptible. In the 
vesicles of the one, there are no central depressions ; in 
the other, central depressions can always be traced, 
either by the naked eye or by the microscope. In the 
true varicella, the crusts are granular, and quickly fall 
off. In the variola varicelloides, the lymph being muci- 
laginous, the crusts are firm, adherent, and drop off, en 
masse, at the end of six or eight days. Authors have 
described pits as having succeeded true varicellous 
eruption, but the occurrence is very rare. I have 
never seen any case where the inflammation ran so 
high as to admit of such a result. 

Hitherto I have not touched upon a question which 
you might naturally suppose would at once settle the 
dispute — I mean, the question of inoculation. Can 
varicella be communicated in this manner X The 



300 INOCULATION OF VARICELLA. 

question is more easily put than answered. Dr. He- 
berden blinks it. He does not say he ever saw inocu- 
lation performed with the lymph of varicella, or rather 
serum (for it is nothing else), but he says that mistakes 
have been made in such inoculations, implying that the 
disease is propagable in that mode. 

Dr. Willan entertained the belief that varicella was 
so communicable ; but his experiments are few, and, to 
my mind, very unsatisfactory. I need not state them 
to you, because, since his time, Mr Bryce, of Edin- 
burgh, by more extended and careful observations, has 
set the question at rest. He states* that he has inocu- 
lated with the fluid of varicella vera, at all periods of 
the disease, and at all seasons of the year, children who 
had never undergone either small pox or cow pox, and 
yet that he had never been successful in producing 
from it either variola or varicella. Since the date of 
Bryce's experiments (1816) I know of none on the 
inoculation of varicella. 

[In the epidemic of varicella at the Hospital Necker in ] 843-44, 
already referred to, M. Delpech was unable to propagate the disease by 
inoculation.] 

What, then, are the arguments which can be brought 
forward in support of the doctrine of identity 1 There 
must be some, seeing that up to the date 1767, certainly 
for 1000 years since the disorder was known, physicians 
adopted that notion, which has even been revived in our 
own times. 

Dr. Thomson's great arguments are these : — 1. Vari- 
cella prevails when variola prevails, and never without. 
Hence, says he, we may deduce the probability that 

* See " Thomson on Varioloid Diseases," page 74. 



NON-IDENTITY OF VARICELLA AND VARIOLA. 301 

one contagion is operating, not two. The answer to 
this argument is, that the facts are incorrectly stated. 
Varicella frequently prevails without variola. Dr. 
Mo hi has shown this most satisfactorily from the expe- 
rience of the Copenhagen epidemics. From J 809 to 
1823, chicken pox was annually observed at Copenha- 
gen without accompanying variola. Since 1823, both 
diseases have prevailed epidemically, but the physicians 
could always trace their sources, and this convinced 
them that the generating miasms were distinct. 

Besides, the doctrine goes for nothing, if it can be 
shown, as has been shown over and over again, that 
some children take varicella after cow pock, and others 
cow pock after varicella, while some have cow pock 
and varicella going through their phases at the same 
time. I have published the details of a case of this 
kind which occurred to me in 1837.* 

Dr. Thomson's next argument is, that he had never 
witnessed chicken pox in those who had undergone 
small pox. I cannot undertake to meet this objection, 
because I see so few children who have undergone 
variola ; and chicken pox is a disease of infantile life. 
I strongly suspect, however, that here also the facts are 
imperfectly known. All I can assure you is, that at 
the Small Pox Hospital no difficulties in diagnosis are 
acknowledged, save in a few rare cases. 

It cannot be doubted for one moment, after reading 
the details of this controversy in the works of Dr. 
Thomson and elsewhere, that a very large proportion 
of the cases of alleged secondary or recurrent small pox 
are really cases of genuine lymphatic varicella mistaken 

* See " London Medical Gazette," vol. h. p. 633. 



302 HERPES. 

for small pox. Several of even the most recent writers 
on cutaneous diseases adopt Dr. Thomson's views, and 
apply the term varicella to those milder forms of variola 
called the modified and mitigated small pox. These 
writers distinctly avow their belief that ail forms of 
varicella without exception are of variolous origin, and 
each susceptible of propagation by inoculation. With 
such views, it cannot be a matter of surprise to anyone 
that the question of recurrent small pox should still be 
so keenly agitated. 

The treatment of varicella demands no comment. A 
little manna and magnesia, wdth abstinence from animal 
food for a few days, comprise all that is essential. 

HERPES. 

This disorder may be thus defined: — 

" An exanthema originating from obscure internal 
causes, and not propagating itself by contagion ; cha- 
racterized by partial clusters of phlyctense or vesicles, 
which are surrounded by areola ; preceded and accom- 
panied by fever, passing through a regular course of 
increase, maturation, and decline, and terminating within 
a fortnight by small scabs." 

Such a disorder was well known to the ancient Greek 
and Roman physicians. The term herpes is derived 
from the Greek fy* Ui to creep. The phlyctenae which 
characterize it derive their name from the Greek 
(pWa»va, a blister; or <pXw, to bubble up. The best 
modern authors on herpes are, Dr. Willan, Dr. Bate- 
man, and Dr. A. T. Thomson, whose essay you will 
find in the " Cyclopaedia of Practical Medicine." 

Nosologists have delighted to form species of herpes. 
Five or six have been so enumerated. I shall be com- 



SPECIES OF HERPES. 303 

pelled to instruct you in their names, but you will bear 
in mind that there is nothing pathologically important 
in these subdivisions. They display merely the inge- 
nuity of the nosologist. The leading variety of herpes 
is that called zoster (from the Greek £ W tf<mp, a belt, or 
£wwupp?, to girdle). By the vulgar in this country the 
disease is familiarly called the shingles — -a corruption 
from the Latin cingulum, a girdle. These denomina- 
tions it receives from the peculiar seat of the herpetic 
disorder, the waist, or rather, a circular line around the 
belly, commencing at the navel. I know of no other 
disorder which specially affects this portion of the 
human body. All other cutaneous affections appear 
on the face, the arms, the lower extremities, the scalp, 
the back, the chest. Herpes zoster alone fixes on the 
belly. 

1. The eruption of herpes is preceded for several 
days, sometimes for a week, by symptoms of general 
constitutional disturbance, occasionally aggravated into 
fever. Languor, low spirits, a succession of bad nights, 
a failing appetite, and weakness of the limbs, betoken 
some lurking disorder. Rigors and flushes, with a 
white tongue, are sometimes superadded, but the febrile 
symptoms, so far as my observations extend, never 
attain any considerable height. 

At length the eruption shows itself, and very fre- 
quently the precise spot will be indicated by a previous 
sensation of heat and itching, sometimes amounting to 
actual pain. I have seen some cases with so little pre- 
ceding constitutional disturbance, that the patient has 
been startled by finding the abdomen occupied by 
eruption. Inflammation first shows itself by the side of 
the navel, followed by the rapid formation of vesicles in 



304 CHARACTERS AND VARIETIES 

clusters. These spread round the belly, generally (but 
not invariably) from right to left ; and a vulgar preju- 
dice teaches, that if they extend entirely round the body, 
the patient dies. This may be said very safely, for such 
an event is scarcely ever witnessed. The eruption 
seldom extends more than half round the body. A 
perpendicular position of the clusters is very rare. 
Raver tells us, he once saw this arrangement on the 
thigh, but on the trunk of the body it is unknown. 

Herpetic vesicles are about the size of a pea. The 
areola surrounding them, which forms very early, is 
often considerable. They attain their maximum ol 
development in three, or at furthest, in four days. The 
contained fluid is at first perfectly limpid, but before 
desiccation, becomes opaque or semipurulent. Dark- 
colored scabs succeed, which harden and fall off in the 
course of a week or ten days, during which time the 
skin cicatrizes. A certain amount of feverishness 
accompanies the maturation of the herpetic vesicles. 
Some relief to the constitutional depression is afforded 
by the development of eruption. 

[The vesicles of herpes vary in size from that of the head of a large 
pin to that of a pea, and sometimes reach a size much larger, by the 
union of two or more at their edges. 

The eruption sometimes commences on one side or the other of the 
median line posteriorly, and sometimes there and at the median line ante- 
riorly at the same time, the groups of vesicles then extending gradually 
from each point of origin until they meet.] 

2. Having thus made you acquainted with the fea- 
tures of the chief form of herpes, I will briefly allude to 
the other varieties of this affection. Clusters of her- 
petic vesicles running the same course with that now 
described sometimes appear on the chest, and extend 



OF HERPETIC ERUPTION. 305 

across the shoulder, in the usual direction of a sword 
belt. They may also show themselves on the extremi- 
ties. The course of the disease in such situations is in 
every respect the same as that of the regular shingles. 
Dr. Willan has distinguished this form of herpes by the 
specific term phlyct anodes. 

3. In some cases the vesicles which appear on the 
arms, shoulders, neck, temples, and groin, assume an 
oval, or sometimes a decidedly circular shape. These 
are called herpetic ringworms. Sometimes there shall 
be one such, sometimes many. To this variety of 
herpes the term circinatus is applied. This form of 
herpes is seldom accompanied by any cognisable con- 
stitutional disturbance. The vesicles are very small, 
and they include a portion of unaffected skin. The 
complaint, if so it may be called, runs its course in 
eight or ten days, but successive crops of vesicular rings 
may procrastinate recovery. Though called a ringworm, 
you will remember that this affection is not contagious, 
like the true ringworm of the scalp (porrigo scutulata). 

4. The term herpes iris has been appropriated to 
those forms of herpetic vesicles which form on the back 
of the hand, and are characterized by the phenomenon 
of concentric circles of vesicles of different colors, yel- 
low, brown, dark red, and light red, corresponding to 
the period of inflammation in each successive crop. 
Their form is generally oval. The iritic form of herpes 
may display itself on other parts, but always where the 
skin is near the bone. 

5. The fifth variety of herpes is the herpes labialis. 
Here the seat of eruption is the upper lip. It is a fre- 
quent attendant on common catarrh, but sometimes also 
appears as an idiopathic affection originating from cold 

20 



306 SOURCES OF HERPES. 

and fatigue, and is then preceded for a day or two, by 
languor, lassitude, nausea, perhaps vomiting, and head- 
ache. I have seen it extend round the whole mouth, 
accompanied by such tumefaction that speaking and 
swallowing were exceedingly painful. The variety of 
herpes termed prseputialis belongs to surgery. 

The sources of herpetic fever and eruption are now to 
be considered. This complaint invariably has its origin 
in irregularity of one or more of the non-naturals, which 
you will recollect to be, air, aliment, the secretions — 
sleep and watching, exercise, and mental anxiety. Any 
irregularities in these will, in certain constitutions, give 
rise to an attack of herpes. Let me give you a few 
illustrative examples. 

A gentleman, accustomed, in his native county 
(Yorkshire), to great regularity of life, came up to Lon- 
don to engage in parliamentary matters. He sat till 
late at night in the heated gallery of the House of 
Commons. He had his meals most irregularly, some- 
times dining in the forenoon, sometimes not till nine 
o'clock at night. His sleep was broken, and his mind 
harassed. After about a fortnight of this system, he 
became languid and oppressed. Herpes zoster, fully 
developed, came to his relief, and in little more than a 
week he was restored to his ordinary condition of health. 

A young lady (Mademoiselle Missonier) came over 
from France to England some years ago. She had a 
very bad passage. The hatches were closed. The air 
in the cabin was stifling. Heat, anxiety, change of air, 
change of diet, change in her habits of life, conspired 
to disarrange the young lady's whole system. Herpes 
labialis in great severity succeeded, on the disappear- 
ance of which her health speedily returned. 



CAUSES OF HERPES. 307 

In January, 1824, Mr. Simpson, one of my earliest 
pupils, passed through a severe form of low fever. At 
the end of the third week, herpes labialis appeared, and 
continued so long, and proceeded to such an extent, 
that for many days he could not speak nor protrude 
his tongue, and hardly could he swallow enough to 
support life. His aspect was hideous. The saliva was 
so offensive that it could not be swallowed for more 
than a fortnight. It yielded at length, and subsided 
much quicker than could have been expected — in about 
six days. No medicine appeared to exert the smallest 
influence over it. 

We may enumerate the following, as some of the 
most usual sources of herpetic affections : — 1. Confine- 
ment to a hot and crowded room (defect of air) ; 2. 
sudden changes in the mode of life (irregularities of 
aliment) ; 3. in infantile life, dentition ; 4. at all ages, 
prior disease of a catarrhal, bilious, or typhoid kind. 

With reference to causes, I would add that in its 
most perfect development, herpes occurs chiefly among 
adults. Children often display clusters of herpetic 
vesicles on the hand, arm, or below the ear, but seldom 
in any notable intensity. Herpes occurs more fre- 
quently in warm than in cold seasons. It attacks 
chiefly those of fine and delicate organization of skin. 
It is therefore more common in women than men. A 
disposition to herpes is hereditary in some families. In 
the London Medical Gazette (vol. ii. p. 632) will be 
found a brief notice by me of a family named Swin- 
burne. The grandfather, uncle, and nephew, had each 
experienced an attack of herpes zoster. The boy had 
it at the early age of nine. It was strongly marked, 
affecting the thorax, and extending from left to right 



308 MILIARIA : 

The treatment of herpes is very simple. In children, 
during the process of dentition, an eruption of herpetic 
vesicles is critical and salutary. So is the herpes labialis 
which succeeds catarrh. Hence we may estimate the 
value of blisters in several forms of infantile feverish- 
ness, of catarrhal and gastric fever. It is often impos- 
sible to repress herpes, and if it were possible, it would 
be highly injudicious. 

Herpes zoster is to be treated by gentle laxative 
draughts, containing senna, magnesia, and its sulphate. 
Whenever herpes or any other febrile eruption is 
attended with much itching of the surface, magnesia is 
a useful remedy, for this itching indicates acidity acting 
on the denuded coats of an irritable stomach. A mix- 
ture of magnesia, mucilage, and the liq. opii sedativi, 
allays the uneasy feeling. You may direct, at the same 
time, a camphorated Saturnine lotion, which cools the 
part. Cold cream is a convenient means of allaying 
irritation. The black wash may be employed to the 
herpetic vesicles so often observed in infantile life. 

MILIARIA. 

The history of medicine presents few chapters so 
discreditable to physicians as that which is devoted to 
miliaria. It would certainly be to our credit to pass it 
over sub silentio, but it is right that you should know 
something about it, and about the controversies to which 
it has given rise. 

Some obscure allusions to miliary eruptions may be 
traced in the writings of Hippocrates, but the term does 
not occur there, nor, in fact, is it anywhere to be met 
with until the middle of the seventeenth century, the 
period which I have already mentioned to you as 



ITS EARLY HISTORY. 309 

famous for the perfection to which medical art had 
brought the heating, or alexipharmic mode of treating 
fever. About that period, some German writers de- 
scribed certain epidemic fevers having miliary eruption 
for their distinguishing character. These epidemics 
happened in 1648, at Lubec ; in 1652, at Leipsic. 
In 1710, Sir David Hamilton, physician to Queen 
Anne, published a regular treatise on miliary fever, the 
English translation of which extends to 256 pages, and 
makes a goodly octavo volume. Later in the eighteenth 
century, it attracted the attention of Dr. Fordyce, in 
London, and of physicians in various parts of the 
continent, among whom may be mentioned, Allioni, 
Fantoni, Walthier, and Gastellier. Sauvages, in his 
"Methodical Nosology" (1768), devotes eleven quarto 
pages to miliaria, and only eight to variola! In 1760, 
De Haen, then practising physic with great success at 
Vienna, attacked the miliary doctors, and being himself 
rather fond of controversy, continued his attacks upon 
them with increasing severity for many years. 

De Haen labors to prove, and certainly to my mind 
succeeded in proving most satisfactorily, that there is no 
form of fever which has miliary eruption for its specific 
or distinguishing feature. " Miliary eruptions," he says, 
" are, like petechia?, accidental occurrences in the pro- 
gress of fevers, which may be encouraged by certain 
modes of treatment, and diminished or entirely pre- 
vented by others." He shows up the inaccurate obser- 
vations and the loose reasoning of physicians concerning 
miliaria during the preceding hundred years, without 
the smallest mercy. 

Notwithstanding these cutting criticisms of De Haen, 
authors continued to write about specific miliary fevers 



310 PHENOMENA OF MILIARY ERUPTION. 

for many years afterwards. Pujol described with great 
minuteness an epidemic miliary fever which prevailed in 
Languedoc in 1782. Since the present century set in, 
however, miliary fever has been at a discount. I know 
of nothing written on it in this country, but Rayer has 
detailed the particulars of an epidemic miliary fever 
which pervaded the department of the Oise (Normandy 
and Picardy) in 1821. The disease is duly noticed in 
all our systematic works. You will see it ably described 
in Dr. Craigie's work " On the Practice of Physic," 
and in the " Cyclopaedia of Practical Medicine," by Dr. 
Tweedie. 

It is greatly to the honor of Sydenham, that he never 
fell into the fashionable theory of miliary fever. He 
was aware of the occasional appearance of miliary vesi- 
cles, and of their causes, and he alludes to them espe- 
cially in his sketch of the fevers of 1685 and following 
years ; but it requires a careful study of his works to 
detect even this incidental mention of them. 

I now proceed to describe briefly (for I need not do 
more) the phenomena of miliary eruption. 

The first appearance of miliaria is preceded by fever, 
with redness and roughness of the skin, especially on 
parts covered by the bed-clothes — the chest, belly, and 
thighs. After a time, the skin thus affected exhibits 
innumerable minute confluent vesicles of the size of 
millet seeds (whence the name, mi!iu??i), of a pearly- 
white color. Now and then small blebs, of a size 
superior to the common miliary vesicles, are seen inter- 
mingled with them. The duration of the eruption is 
uncertain, being, in point of fact, determined by the 
treatment pursued. Authors generally allowed a week 
for the continuance of the eruption, and state that it 



APPEARANCES OF MILIARY ERUPTION. 311 

then terminated by thin crusts, with general desquama- 
tion of the cuticle. 

The symptoms which by the authors of the seven- 
teenth century were considered as the initiatory signs of 
miliaria were, sighing, oppression of the prsecordia, rest- 
lessness, panting of the breath, jactitation, cramps, sub- 
sultus tendinum, and a sense of fulness and faintness. 
"I knew," says Sir David Hamilton (describing the 
case of Mr. Bullock, August 8, 1700) — "I knew, by 
the oppression of the breathing, and the languor and 
faintness of the spirits, that this would end in a miliary 
fever." It is scarcely needful to apprise you, that these 
symptoms indicated congestion of blood about the lungs 
and great vessels. The miliary eruption is accompanied 
by a pulse always rapid, and generally small. Some- 
times, however, we read of a hard, irregular, and inter- 
mitting pulse, co-existing with a crop of miliary vesicles. 
The tongue is often clean and moist. Much thirst is 
usually present. 

Miliary eruptions (termed by the old authors suda- 
mina) are always associated with a moist state of the 
surface, and the odor of the sweat is singularly rank, 
offensive, and acid. This is the clue to the theory of 
miliary eruption. It never appears under a cool treat- 
ment, or with a cool condition of surface ; but it may 
appear in any fever where the surface is either naturally 
very hot, with a strong and full action of the heart and 
arteries ; or where such a condition of surface is 
brought on artificially, either by sweating drinks, or by 
stimulating medicines, or by superabundant bedclothes, 
or the excessive heat of the weather, or the great exer- 
tions of the patient. To give you some examples: — 

1. Miliary eruptions have always been observed in 



312 APPEARANCES OF MILIARY ERUPTION. 

the lying-in room. To this three things contribute : 
the exertions of the woman, the closeness of the cham- 
ber, and the caudle with which the officious nurse sup- 
plies the object of her care. The febris puerperarum 
miliaris is described by Hoffman, and all the writers of 
that day (1700). It is still occasionally seen under the 
same circumstances. 

2. Miliary vesicles occur occasionally in the early 
stages of all fevers whose natural tendency is to d eve- 
lope eruption. They are observed, therefore, and have 
been already noticed, as accompanying the outbreak of 
small pox, measles, and scarlatina, and that without the 
additional aid of heating or forcing medicines. 

3. Miliary vesicles appear in the progress of all 
fevers treated by sweating remedies. You will remem- 
ber that it was in 1640, when this method of managing 
fevers had attained its acme of absurdity, that miliaria 
first attracted the special attention of physicians. The 
most complete and universal eruption of miliaria which 
I ever saw was in the case of a young man, aged 
eighteen, laboring under acute rheumatism. His first 
medical attendant had enveloped his body in folds of 
flannel from head to foot, giving him very much the 
appearance of a mummy. When I took charge of the 
patient and unrolled this living mummy, the most 
superb crop of miliary vesicles was displayed which I 
had ever seen, or ever expect to see again. The effect 
of such local treatment, and of the guiacum, camphor, 
and Dover's powder, which formed so prominent a part 
in the old treatment of rheumatic fever, is not only to 
drive the blood to the surface, but to gorge the large 
vessels of the lungs. Hence the dyspnoea. Now, if 
the blood is detained in the lungs and the cutaneous 



CAUSE AND TREATMENT. 313 

capillaries, it cannot be in the heart. The supply of 
blood to the heart, therefore, is imperfect, and hence 
the fainting which made Sir David .Hamilton know 
that his patient was going to have miliary fever. Cool 
the skin, and the tendency to faintness goes off, because 
the blood is then driven towards the heart. Upon this 
principle you treat a young woman who has fainted at 
church, when the congregation and the gas-lights are 
alike numerous. 

When miliary eruptions occurred in the progress of 
typhus fever, it was generally remarked that they ap- 
peared about the tenth day of the fever, and declined 
about the eighteenth. All authors agreed that no criti- 
cal days were perceptible. Sometimes fresh crops of 
vesicles would appear and protract recovery. 

Attempts have been made to propagate miliaria by 
inoculation, but, as you might anticipate, without effect. 

Miliaria, then, is chiefly an artificial exanthema. I 
w 7 ill not say but that fevers may exist which have 
a greater tendency than others to develope miliary 
vesicles, but the idea of a purely miliary fever is now 
abandoned. 

The cure of the complaint need not detain us long. 
The cause is, superabundant warmth and too violent 
action of the heart and arteries. When, therefore, you 
chance to meet this disorder, banish from your thoughts 
whatever you may have read as to the danger of sup- 
pressed eruption, and have no scruples about repressing 
it. Throw off superfluous bedclothes, admit cool air 
into the apartment, refresh the skin by tepid ablution, 
provide the patient with cool, subacid drink, exhibit a 
mild laxative, and withdraw all stimulants. You will 
not then long be troubled with miliary eruptions. 



314 PEMPHIGUS AND POMPHOLYX. 



PEMPHIGUS AND POMPHOLYX. 

These terms designate such forms of cutaneous dis- 
ease as are characterized by the appearance of large 
vesicles, blebs, or bullae. Three varieties of bullous 
disease have been described, viz. — the acute pemphi- 
gus, the chronic pemphigus, or pompholyx, and the 
infantile, or gangrenous pemphigus. None of these are 
common, but the most frequent is the chronic variety, 
which I may begin by noticing. 

1. Chronic pe?nphigiis, called also pompholyx, exhibits 
a succession of blebs on different parts of the body, with 
very little surrounding inflammation. No fever is pre- 
sent, and in many cases the evidences of constitutional 
sympathy are few and obscure. It is chiefly met with 
in the aged, and in those whose constitutions have been 
brought below par by debilitating causes, such as low 
diet, fatigue, anxiety, intemperance, residence in damp 
situations, diseased liver, or some other form of visceral 
disorganization. It is always symptomatic of a weak- 
ened, and very often of a broken down constitution. I 
saw a remarkable instance of the complaint many years 
ago in a woman seventy years of age. Her face, arms, 
thighs, and buttocks were occupied by numerous blebs, 
of the size of walnuts. Their usual aspect was trans- 
parent, but some were livid, and these, when broken, 
displayed a dark subjacent corion. She died in the 
course of a few months, deriving very little benefit from 
the plans of treatment which I had adopted. It 
appeared to me to be pathologically allied to erysipelas ; 
to be, in fact, an erysipelas erraticum, solitary blebs 
taking the place of the usual diffused inflammation 
with phlyctense or blisters. 



PEMPHIGUS GANGRENOSUM. 315 

The treatment of chronic pompholyx is neither well 
established nor very satisfactory I have seen blood 
drawn from the arm without either benefit or aggrava- 
tion of the symptoms. A warm bath is a good pallia- 
tive. Dr. Bateman praises bark, cordials, and diuretics. 
Sarsaparilla would naturally suggest itself as an appro- 
priate alterative and tonic. 

2, Dr. Bateman did not acknowledge the existence 
of any form of fever sufficiently marked to merit the 
title of acute pemphigus, but the old authors describe a 
febris bullosa, and a few modern pathologists have done 
the same thing. The acute pemphigus is described as 
throwing out its peculiar eruption after a varying num- 
ber of days of fever. The abdomen and lower extre- 
mities are the usual localities. The subjacent corion, 
when exposed, appears red and tender. The disorder 
may last a week, or be protracted to a month. It is 
occasionally associated with gastro-enteric irritation and 
an aphthous state of the mouth. It is scarcely con- 
sistent with sound pathology to view this otherwise 
than as an accidental complication of bullae with dysen- 
tery or typhus. As such it ought to be treated. 

3. The pe?nphigus gangrenosum of infants has been 
ably described by Dr. Whitley Stokes in the Dublin 
Medical and Physical Essays. It is chiefly met with 
in children under five years of age. It commences 
without fever. Numerous blebs and vesicles appear on 
the skin, succeeded by sores, discharging a thin ichor. 
Sloughy ulceration destroys the skin and neighboring 
textures, and speedily exhausts the already weakened 
child. The chief seats of the blebs and sores are the 
ears, mouth and lips, hands and feet, the genitals, breast, 
and belly. The disorder prevails more in winter than 



316 PEMPHIGUS GANGRENOSUS. 

in summer, and affects those especially who reside in 
damp localities. 

It is obviously a disease of the same nature as the 
cancrum oris that succeeds measles. It is briefly 
alluded to by Dr. Bateman under the title of Rupia 
escharotica. Its treatment must be conducted on the 
principles applicable to gangrenous affections occurring 
in exhausted habits. 

This disorder is known in Ireland by the name of the 
Hives, and it would appear from the population returns 
that a large number of children in that country die 
annually from such a disease. 



LECTURE XIII. 

THE NON-CONTAGIOUS EFFLORESCENCES. 

Lichen. Its characters and chief varieties. Lichen febrilis of adults. 
Diagnosis of lichenous and variolous eruption. Lichen febrilis of chil- 
dren. Varieties of strophulus. Syphilitic lichen of adults. Lichen 
tropicus, or prickly heat. Urticaria febrilis. Its characters and causes. 
Roseola. Its several varieties. Roseola exanthematica. Erythema. Its 
relation to roseola and erysipelas. Notice of the several varieties of 
erythema. Character, course, and treatment of the erythema nodosum. 
Pathological connexion of fever, efflorescence, and specific exanthem. 
Conclusion. 

We come now to the consideration of those forms of 
febrile eruption which are not associated with actual 
inflammation of the corion, and consequently exhibit 
no traces of fluid effusion. We call them the simple 
efflorescences, and they have for their common patholo- 
gical feature a more than average supply of blood to 
the cutaneous vessels. They are four in number : — 
lichen, urticaria, roseola, erythema. 

LICHEN. 

The term xsj^v was introduced into medical litera- 
ture by Hippocrates, who applied it to designate a 
species of chronic tetter, the precise nature of which is 
unknown. Since the adoption of Dr. Willan's system 
of cutaneous nosology, lichen is appropriated to an 
eruption (sometimes attended, sometimes unattended, 
by fever) consisting of small elevated papulae, which do 
not run into vesicle or pustule, but terminate by scurfy 
desquamation. Such a disorder acknowledges various 



318 CHARACTERS AND VARIETIES OF LICHEN. 

causes, and occurs under very opposite conditions of 
the body. It is not contagious, is dependent on no 
miasm, and may recur frequently to the same indi- 
vidual. 

Such is the definition of lichenous eruption. Dr. 
Willan has introduced into his work a great variety of 
species of the genus lichen — viz. the lichen simplex, 
agrius, circumscriptus, pilaris, lividus, urticatus, and tro- 
picus. Every trifling alteration in the appearance of 
the eruption has been magnified into importance, and 
been made the foundation of a species. I cannot see 
the utility of these learned minutiae. When the differ- 
ences are such as indicate important distinctions in 
pathology, or affect materially the treatment, they may, 
and indeed ought to be adopted, but not otherwise. 

1. The first kind of lichen that I shall describe to you 
is the lichen febrilis of adults. 

This complaint is one of the most frequent sources of 
difficulty and error in exanthematic diagnosis. A modi- 
fication of febrile lichen, perhaps the disorder itself, is 
called by some " rubeola sine catarrho." Lichen is fre- 
quently mistaken for true measles, and almost as often 
for small pox. Not a year passes over without our 
receiving, at the Small Pox Hospital, three or four 
patients having this form of febrile eruption ; and, to 
confess the truth, I have myself, in former times, mis- 
taken the complaint for small pox. 

Lichen febrilis affects chiefly adults. Its familiar 
designation is, a surfeit. Its most usual cause is, sudden 
exposure to cold when the body is perspiring profusely. 
Hence, by far the most frequent subjects of it are cooks, 
who, in their usual callings, are suddenly taken from 
before a huge Christmas fire to a cold scullery or a 



DIAGNOSIS OF LICHEN. 319 

damp coal cellar. But lichenous eruptions display 
themselves where the same cause cannot he traced. 
We are justified, therefore, in concluding that other 
" vices of the non-naturals" (to use the language of our 
professional forefathers) may occasion lichenous fever 
— such as irregularities of exercise, sleep, and diet. 
Modern pathologists concur in attributing a large pro- 
portion of such cases to disturbance in the gastric and 
hepatic functions, and there can be no doubt but that 
the skin sympathizes largely in the morbid affections 
of the liver and stomach. The old authors were fully 
alive to the importance of this doctrine, and mentioned 
the vitia secretorum et excretorum as leading to lichen. 
An eruption, truly lichenous in its character, is frequently 
associated with typhoid fever. It is perhaps the most 
constant of all the evidences of secondary syphilis. 

Febrile lichen has an incubative stage of twenty-four 
hours only. This is the great secret by which to effect 
the diagnosis of lichen from the greater exanthemata 
(small pox and measles). There is here the same lan- 
guor and lassitude, the same sickness, restlessness, debi- 
lity, and loss of appetite, the same confusion of intellect, 
and general diminution of secretion, which characterize 
eruptive fever under other circumstances. Lichenous 
eruption usually appears over the whole surface of the 
body at once. I have seen it in the course of twelve 
hours as vivid on the lower as on the upper extremities. 
This happened to me, to witness, on one occasion, in 
consultation with Mr. Money on the case of a young 
woman who had travelled up by railway from Birming- 
ham. The confusion prior to her journey, and the heat 
during and succeeding it, had, in common parlance, 
heated her blood. The result was, a sudden and severe 



320 DIAGNOSIS OF LICHENOUS ERUPTION. 

burst of febrile lichen. A few days of rest restored the 
system to its normal condition, but in the meantime 
great alarm had been taken in the fashionable hotel at 
the west end of the town in which she was lodged, 
under the persuasion that confluent small pox had 
broken out there. 

The eruption of febrile lichen is sometimes nearly as 
vivid as that of scarlatina, but generally it is of the 
darker or venous color, characteristic of rubeola. Some- 
times its color is so deep as to induce nosologists to 
dignify the occurrence by the name of lichen lividus. 
The eruption of lichen is decidedly papuliform. Ele- 
vations of the skin in the form of pimples, close set, or 
confluent, and very extensively diffused, can be per- 
ceived. The eruption is accompanied by considerable 
itching. Its usual course is as follows. On the second, 
or at furthest, the third day, it fades. The associated 
fever diminishes. The patient expresses a desire to get 
up, and in less than a week is again at her ordinary 
employments ; I say, her employments, because the 
disorder is so much more common in females than in 
males. 

The diagnosis is to be effected — 1. by inquiry into 
the prior history of the patient; 2. by the shortness of 
the incubation ; 3. by the character of the eruption ; 4. 
by a comparison of the quantity of eruption with the 
intensity of the accompanying fever. The eruption, 
from its amount, would perhaps suggest the idea of 
small pox, but the fever necessary to develope so much 
variolous eruption would not correspond with that 
which would be present in a case of lichenous eruption, 
however full and confluent. 

Lichen febrilis is a disease of no danger. It arises 



LICHEN FEBRILIS OF CHILDREN. 321 

from causes not affecting any of the great organs essen- 
tial to life. It therefore never appears in the tables of 
mortality. A few doses of opening medicine, low diet, 
and some saline draughts, include all that is essential 
with regard to treatment. 

2. Lichen febrilis of children. During the process of 
teething, and again when under process of vaccination, 
still more frequently when these two processes are 
goiug on simultaneously, children are very liable to be 
attacked with lichen. The complaint, as it occurs in 
infantile life, is called strophulus by most authors, but 
the character of the eruption is simply lichenous, some- 
times with, sometimes without, sympathetic fever. 
Strophulus — the red gum or infantile lichen — has been 
split and subdivided by the cutaneous nosologists into a 
variety of species, the specific differences being some 
accidental and unimportant shade of color, or unusual 
mode of grouping of the papulae. It will be sufficient 
to have merely enumerated them. They are — stro- 
phulus intertinctus, albidus, confertus, volaticus, and 
candidus. Many cases of strophulus are compatible 
with a good state of health, and really require no medi- 
cal treatment whatever. 

When lichenous eruption arises in the infant from 
the vaccine poison, it usually shows itself on or after 
the eighth day. It is most common in the warm 
months of the year, and in children nourished on a 
good breast of milk, and full of blood. But peculiarity 
of habit will suffice to develope it in some children 
without such contingent circumstances. It frequently 
occasions great uneasiness to the parent, who is 
impressed with the belief that her infant has taken 
small pox, or been vaccinated from an unhealthy chi.d 

21 



322 CHRONIC LICHEN. 

■ 

or cut with a foul lancet. None of these notions are 
founded in reason. Vaccine lichen may continue to 
show itself for ten days. It then gradually subsides, 
especially with the aid of a little aperient medicine. A 
powder containing one grain of calomel with five of 
jalap and five of rhubarb, may be divided into four 
parts, of which one should be taken daily. 

3. Lichen chronicus syphiliticus. The third variety 
of lichen is that which attacks adults in a chronic form, 
as the secondary offspring of the venereal poison. To 
describe the appearances of venereal lichen is the duty 
of the lecturer on surgery. I have no wish to poach 
upon his manor, but as the diagnosis of exanthematic 
affections may be materially aided by your knowledge 
of lichen syphiliticus, I may tell you briefly the princi- 
pal points in its history. This variety of lichen has its 
chief seat between the shoulders, and it sometimes 
extends over the whole back. It is often accompanied 
by, or alternates with, syphilitic iritis, or syphilitic 
affection of the throat. It is rarely, if ever, associated 
with fever. It is very chronic in its nature, often per- 
sisting for three weeks or a month. I have known it 
to continue for upwards of a month, especially where 
no remedial measures are adopted for aiding the elimi- 
nation of the poison. This kind of lichen is much 
benefited by gentle doses of blue pill, and decoction of 
sarsaparilla with hydriodate of potassa. 

[The papular form of syphilitic eruption is also very frequently seen 
on the limbs, of which it most commonly occupies the external surfaces, 
and is. very rarely found on the chest or on the abdomen.] 

These are the three varieties of lichenous eruption 
chiefly observed in this country. It remains that I 
notice one other, exceedingly common in hot climates, 



LICHEN TROPICUS. 323 

where it is known by the name of the prickly heat. 
From nosologists it has received the appropriate name 
of lichen tropicus. 

All Europeans, on their first arrival in a tropical 
climate, suffer more or less from this affection. It is 
the direct effect of the burning rays of a vertical sun 
upon the tender and irritable white skin, unprotected 
by a rete mucosum and its black pigment. Many con- 
tinue to suffer from it in spite of acclimatization. We 
can sometimes trace, even in this climate, during the 
months of July and August, an approach to the lichen 
tropicus. The character of the eruption is purely 
lichenous — that is, papulae elevated, but not advancing 
to fluid effusion. The great peculiarity of lichen tropi- 
cus is the intolerable pruritus or itching which accom- 
panies it. All that we see of the itchiness of lichen in 
this country gives but a faint picture of the miseries 
endured by the unhappy European suffering under 
lichen tropicus in the East Indies, especially when the 
cutaneous circulation is excited by such exercise as 
brings out perspiration, by drinking wine, or even 
taking hot soup at dinner. The sensation is a horrid 
compound of heat, tingling, itching, and pricking. The 
cold bath rather aggravates than appeases the sufferings 
of the patient, especially during the glow that succeeds 
the immersion. 

We have the high authority of Dr. James Johnson 
for saying, that until the constitution becomes assimi- 
lated to the climate, the only thing that can be done is, 
to use light clothing ; to be temperate both in eating 
and drinking ; to avoid all exercise in the heat of the 
day ; to keep the bowels gently open ; and to resist, 
with stoical firmness, the disposition to scratch. 



324 URTICARIA, 

j [An analogous form ©f eruption is very common here during the 
excessive heat of our summer months, and is quite mild, being attended 
with but very little itching, and rarely leading those who have it to 
seek for medical aid. It occurs chiefly on parts exposed to the sun.] 

URTICARIA. 

The febrile urticaria, or nettlerasli, is an exanthema? 
usually of a very mild or benignant kind, possessing the 
following characters : — 

It displays elevations of tiie outer surface of the 
corion, of considerable extent, and usually of a circular 
form, of a white color, to which the term wheals is 
popularly applied. These eminences r or wheals, are 
sometimes persistent, but more commonly they fade 
during the day and return with the return of night. 
They are always attended with troublesome itching, 
and the affected parts are hot The accompanying 
fever is sometimes severe. Sometimes little or no con- 
stitutional affection is perceptible. It occurs to persons 
of all ages, and acknowledges several sources,, but has> 
no origin from miasm. 

Urticaria, like lichen, has been a favorite complaint 
with nosologists. Every minute deviation from the* 
ordinary character of the eruption has been the signal 
for the creation of a fresh species. I know but of two 
kinds of urticaria, the acute and the chronic ; but Dr. 
Willan gives us no less than six. The chief source of 
the disease is to be found in some peculiar irritability 
of the skin. Those who once suffer from it are liable 
to it again and again. In such a condition of the sur- 
face, many causes suffice to bring on an attack. 

1. The simplest form of urticaria is that which arises 
from the local application of nettles. Hence the name 



URTICARIA FEBRILIS. ' 325 

— urtica, a nettle, Some animals of the molluscous 
kind have a like effect upon the skin. 

2. The acute or febrile urticaria is a well marked 
variety of exanthema, of which, in the course of my 
life, I have seen several striking examples. The incuba- 
tive stage is short, and presents no peculiar characters. 
This eruptive ailment is attended with constitutional 
excitement, or fever, much more intense than the 
nature of the exanthem would lead you to expect. 
The heat of skin is often as great as in scarlatina. 
The pulse is active. Delirium and other evidences of 
constitutional disturbance are sometimes met with. 
Dr. Elliotson first taught me the necessity of taking 
blood from the arm in severe cases of febrile urticaria. 
The blood will be found highly cupped and buffy, 
evidencing the inflammatory nature of the disorder. I 
have followed the practice with great advantage, and 
strongly counsel you to pursue the same line of treat- 
ment. On several occasions I have tried to do without 
it, and have failed. The itching and heat accompany- 
ing febrile urticaria are great sources of discomfort. 
They admit of partial relief from the use of the decoc- 
tion of bran, with a little spirit of rosemary. Purgative 
medicines are useful, but it is better to draw blood 
moderately from the arm, than to attempt to subdue 
any considerable amount of inflammatory fever by pur- 
gatives alone. 

I know nothing of the immediate causes of the febrile 
urticaria different from what I stated with reference to 
the acute forms of herpes and lichen. Any notable 
deviation from the ordinary course of life may end in 
an attack of acute urticaria. Severe exercise, exposure 
to cold, a draught of cold water taken when the body 



326 CAUSES OF FEBRILE URTICARIA, 

is overheated, may prove an exciting cause, AH the 
more urgent cases of urticaria, therefore, occur in per- 
sons between the ages of fifteen and twenty-five, but 
other periods of life are not exempt from the malady. 
The vaccine poison, when developed in great abun- 
dance in a plethoric child, has brought out urticaria, 
with some fever. Certain articles of food will produce, 
in particular habits, where the skin is irritable, an 
ephemeral feverishness, during which an J urticarial 
exanthem shall display itself. Almonds, or prussic 
acid in any shape, has this effect on some; lobsters, 
shrimps, and certain other kinds of shell-fish, on others. 
Cucumbers, vinegar, cayenne pepper, honey, mush- 
rooms, and other vegetable substances not possessing 
any particular noxious principle, will have a like effect 
on a third class of persons. 

This latter kind of urticaria is very evanescent. A 
gentle emetic, followed by a mild laxative, suffices for 
its cure. 

3. A chronic form of urticaria has been observed, in 
which the eruption appears and recedes alternately for 
a great length of time, without fever or any perceptible 
derangement of the general health. It probably arises 
from some irregularity of diet, such as over-indulgence 
in wine, or food of too stimulating a quality. According 
to the permanence, extent, or firmness of the wheals, 
the disorder is denominated urticaria evanida, perstans, 
conferta, subcutanea, or tuberosa. 

In all these chronic forms of urticaria, warm baths, 
restrictions on diet, with the use of magnesia, or other 
simple laxative, are generally found adequate to effect 
a cure. 



VARIETIES OF ROSEOLOUS RASH. 327 



ROSEOLA. 

The term roseola is appropriated to a mild rash of 
a rose color, appearing in patches of irregular shape, 
without any pimples or perceptible elevation of the 
corion. This disorder is accompanied by a light 
evanescent febricula, and is not contagious. 

Little need be said concerning a disorder which, 
except as it may lead to mistakes in diagnosis, would 
hardly be reckoned worthy of notice. On that ac- 
count, however, the circumstances under which it 
appears deserve some attention. 

1. A roseolous eruption occurs in the hot months of 
the year, and occupies (as roseola generally does) the 
face and upper parts of the body. It is called the 
roseola sestiva, and if accompanied by any affection of 
the throat is probably a mild variety of scarlatina. 

2. I have occasionally seen roseola in females of ple- 
thoric habit and irritable temperament. In them, a 
little extra exercise, an additional glass of wine, nay, 
sometimes emotion of mind, will throw out a roseolous 
rash over the neck and bosom. Such women may be 
said to blush, not only with the cheeks, but with the 
whole upper part of the body. 

4. A roseolous rash occurs often in children in con- 
nexion with dentition (roseola infantilis). 

5. The most important of all the varieties of roseola 
is the roseola exanthematica, or variolosa. It happens 
occasionally that after one, two, or three days of fever,, 
a roseolous rash is suddenly thrown out over the face, 
neck, arms, and back, in irregular patches. In some 
cases, this eruption assumes the aspect of scarlatina. 
On the second or third day from the appearance of this 



328 ROSEOLA EXANTHEMATICA. 

rose-colored or scarlet rash, pimples display themselves 
in the very midst of these patches. These gradually 
advance, and in three days more show the depressed 
centres of variola. The occurrence is very annoying 
in practice. The physician first pronounces that his 
patient has fever. Two days afterwards he changes 
his note, and informs the friends that the patient, 
besides fever, has the roseola, or rose-rash, an affair of 
no consequence. Two days after that, he announces to 
the astonished listeners that the patient has small pox ! 
This once occurred to myself in consultation with Mr. 
Hammond, at Windsor. Three diseases in as many 
days ! The unprofessional man considers this impos- 
sible, and is perhaps disposed to question the sagacity 
of his medical attendant, but in this he is wrong. He 
is deceived, because he has neither studied the pheno- 
mena of exanthematic nisus, nor reflected on the 
manner in which exanthematic maladies slide into each 
other. 

Roseola exanthematica frequently accompanies the 
incubative stage of post-vaccine small pox. It indicates 
invariably the advent of a mild form of variola. Tt was 
a frequent attendant on the inoculated small pox, and 
always hailed as a good omen by the professed inocu- 
lators. The most perfect specimens of roseola which 
can now be seen are those which attend the develop- 
ment of cow pox in some children of irritable habit and 
delicate skin. 

The treatment of roseola offers no topic of sufficient 
importance to arrest our attention. I have seen one 
case where the urgency of febrile tumult demanded the 
abstraction often ounces of blood from the arm. 



VARIETIES OF ERYTHEMA. 329 



ERYTHEMA. 



The last in the series of eruptive fevers is erythema, 
which is so closely allied to roseola that it is only a 
stretch of nosological refinement which has separated 
them into distinct disorders. The term spu&r^a, as used 
everywhere by Hippocrates, simply denotes redness ; 
and it is therefore correctly applied to any disorder 
having for its character simple efflorescence, not accom- 
panied by swelling, and not advancing, under common 
circumstances, to vesication. But this is the nosological 
definition of roseola. Having so many terms, there- 
fore, to express the same thing, we cannot wonder that 
modern authors should have differed in their acceptation 
of the term erythema. Some hold it to be merely the 
mildest form and earliest stage of erysipelas ; others 
restrict the term to such cases as exhibit redness of the 
skin, in patches, with some concomitant constitutional 
disorder, but neither originating in a contagious miasm, 
nor terminating in fluid effusion. In this sense I shall 
employ the term, but I shall not detain you long either 
with the history or the pathology of the disease. Ery- 
thematous eruption, indeed, offers little to interest us, 
though, as usual, nosologists have done their best to 
turn that little to good account. Dr. Willan describes 
six species, varieties, or rather, as we ought to say, 
shades of erythema, to which he gives the names of 
erythema fugax, laeve, marginatum, papulatum, tubercu- 
latum, and nodosum. Without attempting any formal 
description of these several kinds of efflorescence, I may 
state briefly all that it concerns you to know concerning 
erythema, its aspects, sources, and most characteristic 
variety. 



330 VARIETIES OF ERYTHEMA. 

Erythematous redness is sometimes obviously depend- 
ent upon the presence of local irritation, such as pres- 
sure, friction, distension, cold, heat, the bites of insects, 
acrid and stimulating applications, wounds, and ulcers. 
At other times, it originates .idiopathically without any 
obvious cause, and is then attributable to some derange- 
ment of the hepatic, gastric, or nervous systems. 

The best illustration I can give you of local erythe- 
matous redness is the areola of cow pox. It does not 
commonly advance to vesicle. We are therefore hardly 
justified in calling it erysipelatous redness. Yet to 
show you how nearly allied are the two disorders 
(erythema and erysipelas), I may state, that occasion- 
ally the vaccine areola does merge in erysipelas, and by 
so doing creates no small alarm in the mind of the 
patient or parent. It is not uncommon to see the 
re-vaccination of adults followed by irregular erysipela- 
tous areola. 

Patches of erythematous redness appear at uncertain 
times in the progress of various kinds of febrile disease, 
especially of the low and typhoid character, and in 
many chronic affections, especially those of gastric or 
hepatic origin. Erythema is an almost constant atten- 
dant on the aggravated cases of anasarca, where the 
skin is put upon the stretch. Under such circumstances, 
it appears in streaks of a dark red or purple hue. The 
intertrigo or chafing to which both infants and aged 
persons are liable, especially when very fat, is of the 
nature of erythema. Sinapisms, pitch plasters, turpen- 
tine, and ammoniacal embrocations, are applied for the 
express purpose of exciting erythematous redness. 
Leech-bites and blisters are often succeeded by an 
extensive erythema of the neighboring integument. All 



ERYTHEMA NODOSUM. 331 

these varieties of erythema are obviously symptomatic. 
The only important question for our consideration is, 
whether there exists any disease having erythematous 
redness for its chief character, sufficiently distinguished 
from erysipelas and from roseola to be entitled to sepa- 
rate examination 1 There is such a disease, and it is 
called erythema nodosum. It is a mild exanthem, being 
often preceded and accompanied by fever. It is distin- 
guished from erysipelas, in that it does not run into 
vesications. It is distinguished from roseola by the 
circumstance of its occupying the lower parts of the 
body, to the exclusion of the upper. 

Erythema nodosum is characterized by patches of 
efflorescence occupying the skin lying over the tibia. 
The patches are oval in shape, the long diameter being 
parallel to the tibia. They slowly rise into hard and 
painful protuberances, and present very much of the 
appearance of nodes. I have seen this disorder ushered 
in by a kind of irregular or low fever, with foul tongue, 
impaired appetite, and a faulty state of the secretions. 
Languor and lassitude have been the predominant 
symptoms, and the patient has often been surprised by 
accidentally discovering the eruption. This complaint 
is chiefly met with in young women between the ages 
of fifteen and twenty-five. I once saw it in a delicate 
lad, the apprentice of Mr. Courtney, formerly chemist 
and druggist in the Regent-circus. 

Erythema nodosum is a tedious disorder, often 
extending to three or four weeks, during the whole of 
which period the only urgent symptoms are languor 
and debility. The eruption subsides as the constitution 
improves. Purgative pills, containing calomel and colo- 
cynth, followed by the infusion of senna with manna, 



332 CONCLUSION. 

are required in the first instance. The acidulated 
decoction of hark may afterwards promote the return of 
strength. 

The same observations which I have made with 
reference to the origin of herpes zoster, urticaria febrilis, 
and lichen febrilis, apply equally to erythema nodosum. 
These febrile efflorescences are all closely associated in 
their pathological features ; they constitute the extreme 
links of that chain which connects the specific exanthe- 
mata with the febrile diseases of the human body, where 
the skin is simply dry. In those fevers you find increased 
action of the cutaneous vessels, but it is neither of that 
kind, nor is it in that intensity which ends in eruption. 

Everything tends to show that there exists in nature 
a great law binding together fever, simple efflorescence, 
and specific exanthem. Throughout the preceding 
lectures, this principle has been frequently illustrated, 
and as it is one of the most interesting which dermatic 
pathology presents, so is it that which warns me that 
here my labors terminate. 



APPENDIX. 



[ A.— Page 6. ] 

EXANTHEMATIC MORTALITY. 

Tables showing the number of deaths in the cities of New York, Phila- 
delphia, and Boston, by the four epidemic diseases, Small Pox, Measles, 
Scarlet Fever, and Hooping Cough, during different decennial periods in the 
different cities, from 1806 to 1845 inclusive; and also the average of the 
mortality by these diseases to the whole mortality. 

I— New York. From 1806 to 1845 inclusive. 





1806-15. 


1816-25. 


1826-35. 


1836-45. 


DISEASES. 

Small Pox . . . 
Measles .... 
Scarlet Fever . . 

Total Exanthe- ) 
matic Mortality ) 
Hooping Cough . 

Total Epidemic ) 
Mortality ) 

Total Mortality . 


Number! 

of percent. 
Deaths* 


Number 

of 
Deaths. 


Percent. 


Number 

Deaths 


Percent. 


Number 

of 
Deaths. 


Percent 


445 

148 

22 




664 

521 

32 




1414 
1005 
1723 




1680 
1559 

2880 




615 
595 




1217 
595 




4142 
1155 




6119 
1194 




1210 


1 in 18 


1812 


1 in 18 


5297 


1 in 11| 


7313 


1 in Hi 


21,867 


or5i 
percent 


32,980 


or5i 
Percent. 


60,854 


or8j 
Percent 


82,364 


or 8J- 
Percent 



Average for the whole period, 1 in 12$ (12-66), or 7£ per cent. (7-89). 

Population in 1810, 96,373. In 1820, 123,706, In 1830, 119,112. In 
1840, 312,701. 



334 



APPENDIX. 



II.— PHILADELPHIA. From 1816 to 1845 inclusive. 



DISEASES. 

Small Pox .... 

Measles 

Scarlet Fever . . . 

Total Exanthematic ) 

Mortality $ 

Hooping Cough . ■ . 

Total Epidemic ) 
Mortality $ 

Total Mortality . . 


1816-25. 


1826-35. 


1836 


-45. 


Number 

..f 
Deaths. 


Per cent. 


Number 

of 
Deaths. 


Per cent. 


Number 

of 
Deaths. 


Per cent. 


649 
451 

78 




1280 

625 
1010 




933 

418 

2214 




1178 
470 




2915 
555 




3565 

709 




1648 


1 in 
18-68 


3470 


1 in 13 


4274 


1 in 12 


30,799 


or 5J 
Per cent. 


45,347 


or 7§ 
Per cent. 


51,454 


orPi 
Per cent. 



Average for the whole period, 1 in 13£ (13*58), or 7£ per cent. (7*33). 
Population in 1820, 119,325. In 1830, 167,811. In 1840, 228,691. 



III.— BOSTON. From 1811 to 1845 inclusive. 



DISEASES. 

Small Pox . . 
Measles . . . 
Scarlet Fever 

Total Exanthe- \ 
matic Mortality ^ 
Hooping Cough . 

Total Epidemic 1 
Mortality $ 

Total Mortality . 


1811-20. 


1821-30. 


1831-40. 


1841-45. 


Number 

of 
Deaths. 


Percent. 


Number 

of 
Deaths. 


Per cent. 


Number 

of 
Deaths. 


Percent 


Number 

of 
Deaths. 


Percent. 


6 



30 




8 


48 




214 
341 
972 




185 
197 

812 




36 

78 




56 

184 




1527 
326 




1194 
201 




114 


1 in 78 


240 


1 in 51 


1853 


1 in 94 


1395 1 in 
U ^\ 815 

| 


«Q4. 1 ' " r V2? ' 
t_a-±i [percent. 


12,379 


<>r 1-94 
Percent 


17,507 


or J0-6 
Percent. 


11,368 p erC ent 



Average for the whole period, 1 in 14 (13*93), or % per cent. 
Population in 1810, 33,787. In 1820, 43,298. In 1835, 78,603. In 
1845,114,366. 



AITENDIX. 



335 



[ B.-Page 8. J 

EXANTHEMATIC MORTALITY. 

Tables showing the number of deaths by the four epidemic diseases, 
Small Pox, Measles, Scarlet Fever, and Hooping Cough, in the cities of 
New York, Philadelphia, Boston, Providence, Lowell, Baltimore, and 
Charleston (S. C), and in the State of Massachusetts (exclusive of Suffolk 
county), during different series of years in the different places, from 1805 
to 1850 inclusive. 

I.— NEW YORK. From 1805 to 1850 inclusive. 



Small Pox . . . 
Measles .... 
Scarlet Fever . . 

Total Exanthe- ) 

matic Mortality $ 

Hooping Cough . 

Total Epidemic ) 
Mortality ij 

Total Mortality ) 
of New York ) 


1805 


1806 


1807 


1808 


1809 


1810 


1811 


1812 


62 
4 


48 
4 


29 
1 
2 


62 

64 

4 


66 



9 


4 
2 


117 
2 


21 
9 


66 
19 


52 
72 


32 
35 


130 
35 


77 
50 


7 119 
44 43 


30 

82 


85 


124 


67 


165 127 
i 


51 162 


112 


2297 


2174 


2236 


1950 


2038 


2073 2431 


2472 



Small Pox . . . 
Measles .... 
Scarlet Fever . . 

Total Exanthe- ) 

matic Mortality $ 

Hooping Cough . 

Total Epidemic ) 
Mortality \ 

Total Mortality > 
of New York ) 


1813 


1814 


1815 


1816 


1817 


1818 


1819 


1820 

74 
5 


2 

35 

1 


2 

15 
1 


94 

18 


179 
19 


14 

20 

3 


19 

18 


10 
5 


38 

89 


18 
50 


112 
95 


198 
44 


37 
11 


37 

123 


15 
55 


79 
19 


127 


68 


207 


242 


48 


160 


70 


98 
3326 


2207 


1881 


2405 


2651 


2409 


3106 


3008 



Small Pox . . . 
Measles .... 
Scarlet Fever . . 

Total Exanthe- ) 

matic Mortality \ 

Hooping Cough . 

Total Epidemic ) 
Mortality \ 

Total Mortality ) 
of New York ) 


1821 


1822 


1823 


1824 


1825 


1826 


1827 


1828 

93 

28 
11 


109 
3 


1 
1 


18 

117 

2 


394 

100 

3 


40 
53 

10 


58 
31 
24 


149 
172 

4 


112 
92 


2 
35 


137 
31 


497 
116 


103 
69 


113 
126 


325 
61 


132 

157 


204 


37 


168 


613 


172 


239 


386 


289 


3368 


3026 


3221 


4091 


4774 


4671 


4890 


4843 





















336 



APPENDIX. 



NEW YORK.— Continued. 



1 

Small Pox . . . 
Measles .... 
Scarlet Fever . . 

Total Exanthe- ) 
matic Mortality ) 
Hooping Cougli . 

Total Epidemic / 
Mortality \ 

Total Mortality ) 
of New York \ 


1829 


1830 


1831 


1832 


1833 


1834 


1835 


1836 ] 


16 
91 

188 


176 

22 

246 


224 
39 

258 


89 
290 
221 


25 

38 

179 


233 

212 
418 


351 

82 
174 


173 
443 

202 


295 
52 

347 


444 
97 


521 

181 


600 
63 


242 
105 


863 
141 


607 
172 


818 
152 


541 


702 


663 


347 


1004 


779 


960 


4734 


5198 


5991 


9975 


5354 


8590 


6608 


7503 





1837 


1838 


1839 


1840 


1841 


1842 1843 


Small Pox 

Measles 

Scarlet Fever .... 

Total Exanthematic ) 
Mortality \ 
Hooping Cough . . . 

Total Epidemic > 
Mortality $ 

Total Mortality ) 
, of New York. ) 


164 
238 
579 


91 

79 

257 


68 
133 

158 


232 
186 
391 


*229 
113 
366 


181 

60 

416 


tll9 
118 
223 


981 
63 


427 
219 


359 
113 


809 
73 


708 
67 


657 
191 


460 
63 


1044 


646 


472 


882 


775 


848 


523 


8182 


7533 


7361 


7868 


8531 


8475 


7933 



Small Pox 

Measles 

Scarlet Fever .... 

Total Exanthematic ) 

Mortality \ 

Hooping Cough . . . 

Total Epidemic ) 
Mortality $ 

Total Mortality ) 
of New York \ 


1844 


1845 


1846 


1847 


1848 


1849 


1850 


20 

51 

225 


425 

136 

63 


141 

17 

114 


53 
275 
142 


}585 
77 
93 


326 
125 
266 


231 
324 
311 


296 
164 


624 
89 


272 
214 


470 
86 


755 
213 


717 
112 


866 
180 


460 


713 


486 


556 


968 


829 


1046 


8127 


9886 


10,079 


14,441 


14,553 


22,373 


15,758 



Population in 1805, 75,770. In 1810, 96,373. In 1815, 100,619. In 
1820, 123,706. In 1825, 166,086. In 1830, 202,589. In 1835, 270,089. 
in 1840, 312,852. In 1845, 371,223. In 1850, 515,394. 



* Including 20 of varioloid. 
I- Including 4.1 of varioloid. 



t Including 2 of varioloid. 



APPENDIX. 



337 



II.— PHILADELPHIA. From 1807 to 1846 inclusive. 1 



Small Pox . . . 
Measles .... 
Scarlet Fever . . 

Total Exanthe- ) 

matic Mortality ) 

Hooping Cough . 

Total Epidemic ) 
Mortality ) 

Total Mortality ) 
of Philadelphia ) 


1807 


1803 


1809 


1810 


1811 


1812 


1813 


1814 


32 

1 

33 
17 


145 

73 

2 


101 
1 
3 


33 
2 
2 


117 

20 

2 


1 
1 


9 


7 


220 
11 


105 
96 


37 
32 


139 
54 


2 

24 


9 
29 


7 
23 


50 


231 


201 


69 


193 


26 


38 


30 


1961 


2145 


1884 


1897 


2249 


2017 


2223 


2041 



Small Pox . . . 
Measles .... 
Scarlet Fever . . 

Total Exanthe- > 

matic Mortality ) 

Hooping Cough . 

Total Epidemic > 
Mortality \ 

Total Mortality i 
of Philadelphia \ 


1815 


1816 


1817 


1818 


1819 

1 

108 
2 


1820 


1821 


1822 


2 


97 


52 


8 
1 


47 
30 


13 


8 


2 
6 


97 
46 


52 
21 


9 
6 


111 
151 


77 
11 


13 
36 


8 
38 


8 


143 


73 


15 


262 


88 


49 


46 


1943 


2225 


2107 


2609 


2979 


3189 


2961 


3334 



Small Pox . . . 
Measles .... 
Scarlet Fever . . 

Total Exanthe- ) 

matic Mortality ) 

Hooping Cough . 

Total Epidemic i 
Mortality ) 

Total Mortality ) 
of Philadelphia \ 


1823 


1824 


1825 


1826 


1827 


1828 


1829 


1830 


160 
156 

8 


325 

102 

8 


6 

38 
8 


3 

101 

4 


100 
9 
1 


107 

58 



81 

53 

9 


86 

7 

40 


324 

79 


435 
42 


52 

40 


108 
43 


110 
51 


165 
57 


143 
37 


133 
35 


403 


477 


92 


151 


161 


222 


180 


168 


4372 


4284 


3539 


3845 


3659 


3971 


4001 


3948 



22 



338 



APPENDIX. 



PHIL ADELPHI A.— Continued. 



Small Pox . . . 
Measles .... 
Scarlet Fever . . 

Total Exanthe- ) 

matic Mortality ) 

Hooping Cough a j . 

Total Epidemic > 
Mortality \ 

Total Mortality ) 
of Philadelphia \ 


1831 


1832 


1833 


1834 


1835 


1836 


1837 


1838 


14 
23 

200 


37 
118 
307 


156 

1 

61 


195 

7 
83 


101 
248 
305 


86 

4 

240 


79 

49 

205 


42 
123 
134 


237 
67 


462 

58 


218 
53 


285 
48 


654 
106 


330 

94 


333 

40 


299 
27 


304 


520 


271 


333 


760 


424 


373 


326 


4939 


6425 


4128 


5073 


5358 


5022 


4881 


5118 



Small Pox . . . 
Measles .... 
Scarlet Fever . . 

Total Exanthe- ) 

matic Mortality ) 

Hooping Cough . 

Total Epidemicj £ 
Mortality j $ 

Total Mortality > 
of Philadelphia $ 


1839 


1840 


1841 


1842 


1843 


1844 


1845 


1846 


5 

3 

225 


63 

2 

244 


259 

119 

83 


156 

24 

220 


36 

1 

395 


17 

3 

269 


190 

90 

199 


251 

6 

221 


233 

191 


309 
4 


461 
6 


400 
197 


432 
16 


289 

101 


479 
33 


478 
104 


424 


313 


467 


597 


448 


390 


512 


582 


4765 


4593 


5293 


5558 


5155 


5187 


5882 


5944 



Population in 1810, 96,664. 
1840, 205,580. 



In 1820, 119,325. In 1830, 167,811. In 



III.— BOSTON. From 1811 to 1850 inclusive. 



Small Pox . ."' .' 
Measles. . .~. 
Scarlet Fever . . 

Total Exanthe- ) 

matic Mortality ) 

Hooping Cough . 

Total Epidemic > 
Mortality $ 

Total Mortality ) 
of Boston. \ 


1811 


1812 


1813 


1814 


1815 


1816 


1817 


1818 


2 
1 






1 


4 
21 


6 
3 


1 


1 

1 


3 

14 




1 


5 


25 
2 


9 
9 


1 

19 


2 

1 


17 




1 


6 


27 


18 


20 


3 


894 


633 


750 


695 


830 


873 


875 


925 



APPENDIX. 



339 



BOSTON.— Continued. 



Small Pox . . . 
Measles .... 
Scarlet Fever . . 

Total Exanthe- ) 

matic Mortality ) 

Hooping Cough . 

Total Epidemic ? 
Mortality j 

Total Mortality ) 
of Boston ) 


1819 


1820 


1821 


1822 


1823 


1824 


1825 


1826 


12 


11 


149 

4 


3 

1 


1 


1 
2 
1 


1 

77 
5 


10 
16 


12 
3 


11 
24 


153 

26 


4 
5 


1 
17 


4 
13 


83 
27 


26 
23 


15 


35 


179 


9 


18 


17 


110 


49 


981 


1014 


1321 


1088. 


1045 


1208 


1362 


1167 



Small Pox . . . 
Measles .... 
Scarlet Fever . . 

Total Exanthe- ) 

matic Mortality ) 

Hooping Cough . 

Total Epidemic ) 
Mortality ) 

Total Mortality ) 
of Boston ) 


1827 


1828 


1829 


1830 


1831 


1832 


1833 


1834 


3 

8 


2 
3 


78 
4 


1 

13 

5 


4 
2 

85 


2 

70 
200 


2 
90 


4 

1 

39 


11 
6 


5 

40 


82 
11 


19 
16 


91 
26 


272 
22 


92 

28 


44 

38 


17 


45 


93 


35 


117 


294 


120 


82 


939 


1159 


1156 


1025 


1353 


1705 


1374 


1440 



Small Pox . . . 
Measles .... 
Scarlet Fever . . 

Total Exanthe- > 

matic Mortality ) 

Hooping Cough . 

Total Epidemic > 
Mortality $ 

Total Mortality > 
of Boston ) 


1835 


1836 


1837 


1838 


1839 


1840 


1841 


1842 


7 

188 

73 


6 
31 
31 


13 
23 
50 


3 

20 

106 


60 

3 

222 


115 

1 

76 


57 

87 
89 


42 

23 

273 


2'68 

44 


68 
17 


86 
19 


129 

28 


285 

34 


192 
70 


233 

37 


338 
23 


312 


85 


105 


157 


319 


262 


270 


361 


1818 


1643 


1743 


1799 


1722 


1841 


1783 


2260 



340 

BOSTON.— Continued. 



APPENDIX. 



Small Pox . . . 
Measles .... 
Scarlet Fever . . 

Total Exanthe- ) 

matic Mortality ) 

Hooping Cough . 

Total Epidemic > 
Mortality \ 

Total Mortality ) 
of Boston $ 


1843 


1844 


1845 


1846 


1847 


1848 


1849 


1850 


55- 

43 

150 


36 
240 


31 

8 
160 


92 
150 

106 


23 
15 

59 


21 

16 

177 


21 
209 
317 


192 
75 
69 


248 
54 


276 
24 


199 
63 


348 

38 


97 
36 


214 
33 


547 
36 


336 

81 


302 


300 


262 


386 


133 


247 


583 


417 


2008 


2054 


2340 


3086 


3853 


3664 


5079 


3667 



Population in 1810, 33,787. In 1820, 43,298. In 1830, 61,392. In 
1840, 85,000. In 1845, 114,366. In 1850, 138,788. 

IV.— PROVIDENCE (R. I.). From 1842 to 1849 inclusive. 



Small Pox . . . 
Measles .... 
Scarlet Fever . . 

Total Exanthe- ) 

matic Mortality ) 

Hooping Cough . 

Total Epidemic i 
Mortality \ 

Total Mortality ) 
of Providence \ 


1842 


1843 


1844 


1845 


1846 


1847 


1848 


1849 


2 
9 

4 


1 

1 
18 


17 

20 


1 

5 

36 


4 

2 

55 


3 

7 
42 


4 

9 

12 


1 

3 

33 


15 
6 


20 

7 


37 
3 


42 
9 


61 
3 


52 

4 


25 
16 


37 

6 


21 


27 


40 


51 


64 


56 


41 


43 


556 


618 


633 


714 


806 


884 


870 


1079 



Population in 1845, 31,753. 

V.— LOWELL (Mass.). From 1839 to 1850 iuclusive. 



Small Pox 

Measles 

Scarlet Fever .... 

Total Exanthematic ) 

Mortality ] 

Hooping Cough . . . 

Total Epidemic ) 
Mortality ] 

Total Mortality of ) 
Lowell \ 


1839 


1840 


1841 


1842 


1843 


1844 


12 


1 

7 


2 

4 

43 


12 
32 


6 


10 
3 


12 
3 


8 
6 


49 
3 


44 
5 


6 
11 


13 

4 


15 


14 


52 


49 


17 


17 


340 


426 


456 


473 


363 


362 



APrENDIX. 



341 



LOWELL.— Continued 



Small Pox 

Measles ■ 

Scarlet Fever .... 

Total Exanthematic ) 
Mortality $ 

Hooping Cough . . . 

Total Epidemic ) 
Mortality $ 

Total Mortality of ) 
Lowell \ 


1845 


1846 


1847 


1848 


1849 


1850 


4 
12 


4 
17 
38 


1 
2 

27 


17 
27 
48 


41 
1 

82 


3 
1 


16 
13 


59 

10 


30 


92 
11 


124 

7 


4 
1 


29 


69 


30 


103 


131 


5 


363 


690 


949 


825 


903 


491 



Population in 1840, 20,790. In 1844, 25,163. In 1846, 28,841. In 1850, 
35,000 (nearly). 

VI.— BALTIMORE. From 1836 to 1849 inclusive. 



Small Pox* .... 

Measles 

Scarlet Fever .... 

Total Exanthematic ) 

Mortality $ 

Hooping Cough . . 

Total Epidemic Mor- ) 
tality I 

Total Mortality of ) 
Baltimore $ 


1836 


1837 


1838 


1839 


1840 


1841 


1842 


1 

1 
30 


52 

141 
134 


71 

4 

141 


2 

57 

112 


9 
32 

71 


1 
6 

74 


1 

103 

27 


32 
43 


327 

69 


216 

18 


171 
75 


112 
9 


81 
35 


131 
63 


75 


396 


234 


246 


121 


116 


194 


2192 


2518 


2476 


2260 


2045 


2247 


2477 



Small Pox 

Measles 

Scarlet Fever .... 

Total Exanthematic \ 
Mortality ^ 
Hooping Cough . . . 

Total Epidemic Mor- ) 
tality 5 

Total Mortality of ) 
Baltimore ) 


1843 


1844 


1845 


1846 


1847 


1848 


1849 


4 
56 


1 
370 


110 
20 

288 


115 
114 
132 


1 

7 
166 


4 

74 

407 


19 
31 

155 


60 
20 


371 
59 


418 
62 


361 
26 


174 

104 


485 
59 


205 
59 


80 


430 


480 


387 


278 


544 


264 


2333 


2665 


2896 


2994 


3414 


3861 


4165 



Population in 1840, 102,513. In 1845, 121,161. 

* Besides 7 cases of varioloid during the 14 years. 



342 APPENDIX. 

Vn.*— CHARLESTON (S. C). From 1822 to 1849 inclusive. 



Small Pox 

Measles 

Scarlet Fever .... 

Total Exanthematic > 
Mortality \ 
Hooping Cough . . . 

Total Epidemic Mor- ) 
tality \ 

Total Mortality in } 
Charleston <> 


1822 


1823 


1824 


1825 


1826 


1827 


1828 


26 
46 


15 


1 
7 


52 
3 


29 
5 


7 


5 


72 


4 


8 
69 


'55 
10 


34 
10 


7 


5 
67 


72 


19 


77 


65 


44 


7 


72 


925 


814 


1059 


840 


764^ 


803 


793 



Small Pox 

Measles 

Scarlet Fever .... 

Total Exanthematic ) 
Mortality j 
Hooping Cough . . . 

Total Epidemic Mor- ) 
tality 5 

Total Mortality in ) 
Charleston \ 


1829 


1830 


1831 


1832 


1833 


1834 


1835 


16 

7 


16 

9 

27 


42 

1 

11 


23 


5 


1 


14 

7 


23 

7 


52 
15 


54 
9 


23 


5 

8 


1 

8 


21 
16 


30 


67 


63 


23 


13 


9 


37 


762 


763 


733 


560 


542 


692 


664 



Small Pox 

Measles 

Scarlet Fever .... 

Total Exanthematic ) 
Mortality \ 
Hooping Cough . . . 

Total Epidemic Mor- ) 
tality ) 

Total Mortality in ) 
Charleston \ 


1836 


1837 


1838 


1839 


1840 


1841 


1842 


15 
1 


7 
9 


8 
56 


51 


2 
9 


1 

6 


30 
15 


16 
25 


16 
12 


64 
9 


51 


11 


7 
25 


45 
9 


41 


28 


73 


51 


11 


32 


54 


1172 


630 


1209 


836 


605 


594 


560 



* It is proper to remark, in connexion with the table exhibiting the mortality of 
Charleston, that of the 452 deaths entered under the head of Scarlet Fever (of 
which 289 were among blacks and 163 among whites), 245 are classed as " sore 
throat" (155 whites and 90 blacks), and the remainder under the head of " scarlet 
fever," in the abstract of deaths for individual years, in the ic census" of that city 



ArFENDIX. 



343 



CHARLESTON.— Continued. 



Small Pox 

Measles 

Scarlet Fever .... 

Total Exanthematic ) 
Mortality ) 
Hooping Cough . . . 

Total Epidemic Mor- ) 
tality $ 

Total Mortality in ) 
Charleston \ 


1843 


1844 


1845 


1846 


1847 


1848 


1849 


50 

1 

30 


9 
54 


16 


1 
20 


11 


1 
5 
5 


6 


81 


63 
21 


16 
6 


21 

7 


11 

18 


11 
2 


6 
3 


81 


84 


22 


28 


29 


13 


9 


697 


553 


570 


607 


548 


614 


798 



Population in 1820, 24,780 (10,653 whites, 12,652 slaves, 1475 free 
colored). In 1830, 30,289 (12,828 whites, 15,354 slaves, 2107 free colored). 
In 1840, 29,261 (13,030 whites, 14,673 slaves, 1558 free colored). 



VIII, 



-MASSACHUSETTS, exclusive of Suffolk County (in which Boston 
is situated). From April 30, 1841 to April 30, 1848, inclusive. 



Small Pox 

Measles 

Scarlet Fever .... 

Total Exanthematic ) 
Mortality ] 
Hooping Cough . . . 

Total Epidemic Mor- ) 
tality $ 

Tot. Mort. Mass., excl. ) 
of Suffolk Co. \ 


1842 


1843 


1844 


1845 


1846 


1847 


1848 


13 

86 
395 


12 

30 

559 


11 
32 

328 


5 

44 
538 


32 

46 

516 


12 
136 

418 


20 

42 

175 


494 
43 


601 
61 


371 

60 


587 
68 


594 
100 


566 
104 


237 

76 


537 


662 


431 


655 


694 


670 


313 


7538 


8293 


8250 


8642 


9211 


10,816 


11,001 



published in 1849 ; while, in a general summary of the causes of death, in a sub- 
sequent part of the same work, the word " sore throat" is not used, and the whole 
number entered there under the head of scarlet fever corresponds exactly with 
those in the tables under the two separate heads of scarlet fever and sore throat. 
In the same tables, there is a separate head for " quinsy," and another for " mem- 
branous sore throat ;" hence, we felt authorized in considering those entered under 
the head of" sore throat" in the tables as cases of scarlet fever. 



344 APPENDIX. 



[ C— Page 18. ] 

The co-existence of two febrile exanthemata in the same individual has 
now been observed in so many instances, and so many cases of it are on 
record, that its occurrence may be considered as beyond doubt. We have 
added a few to those mentioned by our author, to show still further on 
what authority this settlement of the question rests, and to illustrate the 
laws by which it is governed. 

Dr. P. Tracy (of Norwich, Conn.) reports (Medical Repository, vol. iii. p. 
105) a case in which measles and small pox occurred at the same time in 
the same individual, and each pursued its regular course without interfering 
with the progress of the other. 

In another case, he inoculated with a variolous matter a young man who 
had been exposed to measles a day or two previously. The variolous 
disease was mild, and progressed regularly, and on the tenth day the pre- 
monitory symptoms of measles appeared, followed the next day by the 
characteristic eruption, which passed through its stages regularly to a 
favorable termination. Neither of these patients had been previously 
affected with measles, but communicated that disease to a considerable 
number of patients in the hospital, who had not been otherwise exposed. 

A case is also stated by Mr. Delagarde, in the 13th vol. of the Medico- 
Chir. Transactions, of the co-existence of measles and small pox, in which 
the characteristic eruption of each appeared at the same time, and ran 
through its course regularly. A child inoculated with matter taken from 
one of the pustules had the small pox. 

Dr. Withering, in his work on scarlet fever (p. 25), alludes to two chil- 
dren (the only two instances he ever saw) who had scarlet fever and small 
pox at the same time. 

Dr. John Watson reports a case (United States Medical and Surgical 
Journal, Oct. 1835, p. 89) of the co-existence of measles and scarlet fever 
in a boy eight or nine years old, examined by himself and another physician, 
and decided to be measles, in whom there appeared, two days after, the 
characteristic eruption of scarlatina, with swollen throat, and red tongue, so 
far as it could be examined, and which proved fatal soon afterwards. He 
subsequently attended two children in the same house with scarlet fever, 
who had desquamation of the cuticle, and anasarca of the legs. 

Mr. Gilder reports a case (Med. Chir. Transac., vol. xii. p. 106) of a 
child, fourteen months old, vaccinated during the premonitory stage of 
measles, in which each disease passed through its regular stages, without 
interference with the other. The progress of the disease was also perfect 
in an infant vaccinated with matter taken from its arm, 

Mr. Little, in a letter to Mr. Dunning, relates an instance of casual 
chicken pox passing through its regular stages, regardless of the local 
action of cow pox, and also alludes to a case of casual measles which came 
under his observation, which progressed undisturbed by the cow pox. 



APPENDIX. 345 

(Comparative Statement of Facts and Observations relative to the Cow Pox. 
London, 1800, p. 28, note.) 

The two following cases are reported by Robert Barnes, M.B. (London 
Lancet, May, 1845), as instances of infection of the system at the same time 
by the poison of small pox and of scarlatina. A girl, nine years old, had 
symptoms of malaise, &c, with a red tongue, fauces injected, and a rash. 
In two days the rash disappeared, and papulae of varioloid appeared more 
distinctly, and ran through their regular course, the patient having vaccine 
scars. At the end of three weeks, she had anasarca. Twelve days after, 
three sisters had varioloid, and another girl in the house had scarlatina. 
One of the sisters also had sore throat. Hence the writer says, " It may be 
fairly presumed, that the first patient served as the common focus of con- 
tagion from whence the two diseases were propagated ; that she not only 
labored under the two diseases conjointly, but transmitted them separately 
to other individuals." 

It is proper to add, that these cases of Mr. Barnes are regarded by Mr. 
Marson as instances of small pox preceded by variola. We have not 
uufrequently seen variola thus preceded, and have not hesitated to regard 
as such some cases which have been reported as those of the co-existence 
of variola and scarlatina ; but, in the present instance, feel that the occur- 
rence of anasarca at the end of three weeks, and the cas^e of scarlatina in 
the same house, furnish strong presumptive evidence in favor of the view 
taken by the reporter of them. 

Mr. Marson, surgeon to the Small Pox and Vaccination Hospital, London, 
in a paper on the co-existence of different eruptive fevers, states that he has 
seen seven cases of the co-existence of variola and scarlatina at that institu- 
tion during the last eleven years, and that three cases had occurred at the 
London Fever Hospital within the last few years. He also alludes to 
numerous other instances of the co-existence of different eruptive fevers. 
(Lond. Med. Gaz., June 18,1847: also Paper on Co-existence of Small 
Pox and Scarlatina, Med. Chir. Trans., vol. xxx. 1847.) 

MM. Barthez and Rilliet have seen scarlatina co-existing with measles 
seven times, variolous eruption twelve times, and erysipelas three times. 

M. Levy, in his memoir on measles in the adult, also gives instances of 
the co-existence of different febrile exanthemata. (Med. Chir. Rev., Oct. 
1847.) 

Dr. John Watson also, in a paper read before the New York Medical and 
Surgical Society, in May, 1835, has collected other cases of such co-exist- 
ence, and also gives in detail some of those to which we have referred. 
(U. States Med. and Surg. Jour., Oct. 1835.) 

The cases quoted by our author (p. 135) from Dr. Russell at Aleppo, of 
the simultaneous occurrence of measles and small pox in the same per- 
son, may be found in the Med. Chir. Trans., vol. ii. p. 90. One was in a 
female child, two years old, and the other in a boy, three years old. In 
both cases, each eruption pursued its regular course, and with a favorable 
result. 



346 APPENDIX. 

We could add still further proof that the febrile exanthemata do exist 
together in the same individual, and run their course simultaneously, but 
feel that the point is too well established to call for any more extended 
notice of the subject. 

[ D.— Page 91. ] 

Numerous reports of isolated cases of secondary small pox, and of 
undoubted authenticity, are on record, and few practitioners, especially in 
cities, pass many years without meeting one or more such cases. We feel, 
too, that statistics will show a frequency of such recurrence greater than 
the views of our author, as expressed in the text, would lead us to antici- 
pate. The subject has of late years derived fresh interest from the increase 
of mortality by small pox after vaccination, the assumed diminishing protec- 
tion afforded by which has inclined some to propose a return to the old 
method of inoculation, on account of the supposed greater protective power 
of variola. We shall leave these topics for a subsequent part of our 
appendix, and confine ourselves in this place to the notice of a few instances 
of such recurrence of more special interest, and to some statistics, to show 
the comparative frequency of second attacks of small pox. 

Mr. E. O. Spooner mentions a case as under his care at the time of 
writing, of a woman, seventy years of age, who, sixty years previously, had 
been successfully inoculated for small pox, and who bore its peculiar marks 
both on her arm and on her body, and was then recovering from a second 
attack of casual small pox. (Provinc. Med. and Surg. Jour., July, 1850.) 

Dr. John Watson, of this city, has reported a well marked case of a 
second attack of small pox in a child two years and ten months old. 
(United States Med. and Surg. Jour., Oct. 1835.) This child we ourselves 
saw, and felt satisfied at the time, from the character of the eruption and 
from the marks left by a former attack, that it was undergoing the disease 
a second time. 

M. Gilet reports a case (VAbeille Med., Paris, Oct. 1844, p. 239) of the 
confluent form in a woman eighty-seven years old, who had a scar of small 
pox on her forehead from the disease in infancy. 

Dr. Renaud gives a case (Revue Medicate, Feb. 1839) of a little girl, 
twenty-eight months old, who had small pox in the distinct form in August, 
1838, and died from an attack of it, in the confluent form, in October of the 
same year. The grandmother on the maternal side had been twice affected 
with small pox, and the mother, who was twenty-six years of age, and who 
nursed the child, and had the disease in her infancy, took it again a short 
time after, and died with it, in the confluent form, on the seventeenth day. 

The frequency of its recurrence, as well as its fatality when it does recur, 
varies with different epidemics. 

In France, in 1840, of 14,470 persons attacked with epidemic small pox, 
it occurred a second time in only twenty-four cases ; and of these, three 
proved fatal. 

In an epidemic in Edinburgh, in 1818, in which 556 cases were seen by 



APPENDIX. 347 

Dr. Thompson of that city, forty-one previously had small pox. Thirty 
other cases were reported to Dr. T., and of the whole seventy-one, three 
died, or one in twenty-three. (Maunsell on Vaccination ; Dublin Med. 
Journ., vol. ii. p. 396.) It will be recollected, however, that Dr. T. believed 
in the identity of small pox and chicken pox, and would, almost of necessity, 
see a larger share of second attacks of variola than could fairly be admitted 
to bear upon the question of the comparative frequency of its recurrence. 

Dr. Mohl, of Copenhagen, records thirty-one fatal cases out of 153 of 
secondary small pox. 

Of 148 cases during the epidemic in Philadelphia in 1823-24, as reported 
by Drs. Mitchell and Bell, eight were in those who had been previously 
affected, and of these four died. 

M. Serres stated to the French Academy of Sciences, in July, 1842 (Gaz. 
Med. de Paris, July 9, 1842), that from an observation of between 1700 and 
1800 cases of small pox in private practice and in hospitals, he could say, 
that cases of a second attack of small pox are as numerous as of attacks of 
small pox after vaccination. 

In Marseilles, in 1828. of 30,000 persons who had been vaccinated, 2000 
were attacked with small pox, and 21 died. Of 2000 who had previously 
had small pox, twenty had it a second time, and four died. 

Dr. Mackintosh says, that he knew upwards of twelve well authenticated 
instances of persons attacked a second time with small pox, and that all his 
cases of secondary small pox, with the exception of two, were remarkably 
severe, whereas he rarely saw a severe case of small pox after vaccination- 
(Practice of Medicine; Phila. edit., 1844, p. 169.) 

On the other hand, we doubt not that the comparative frequency of such 
recurrence has been sometimes much overrated. The Committee of the 
Provincial Medical and Surgical Association say, for instance, (Trans. Prov- 
Med. 6f Surg. Assoc, vol. viii, p. 67,) that, according to the most accurate 
calculation they can make, there cannot be fewer than 239 cases recorded 
by sixty-two correspondents ; and that of these, twelve or thirteen proved 
fatal. We feel confident that some allowance should be made for errors in 
diagnosis, and perhaps for the influence of the probable prevalence, to a 
considerable extent, of the views of Dr. Thompson, before alluded to, in 
favor of the identity of small pox and chicken pox, in weighing the authority 
of the communications to that body, made as they were by practitioners scat- 
tered throughout the country ; and, perhaps, the same remark may be appli- 
cable to at least a part of the writers referred to by Dr. Baron, the chairman of 
that committee, who, "in his Life of Jenner, (vol. 1, p. 266,) says, that more 
than one hundred and thirty different writers may be named who have 
reported cases of secondary or recurrent small pox, many of these being 
probably the same as those quoted by that committee. Indeed, the veiy 
low rate of mortality, according to their own figures, is strong presumptive 
proof against the genuine nature of all the cases thus reported to that 
committee, the deaths having been only in the proportion of 1 in 19. 



348 APPENDIX. 

We feel bound, also, freely to acknowledge the authority due to the 
opinion of our author, so strongly expressed in the text, in favor of the infre- 
quency of such recurrence, founded, as it is, on careful observation, for so long 
a series of years, and under such favorable circumstances; and to record, in 
addition, the striking fact stated by him in a letter recently received, that> 
during the last forty-one years, but one single case of recurrent small pox 
has been reported to the Medical and Chirurgical Society of London, the 
last and only recorded case in their transactions being one by Dr. Bateman 
in 1810. One case, adds Dr. G., did occur in London, about twenty years 
ago, but was not reported. 

While, therefore, we feel that facts will fully warrant the fear that second 
attacks of this cruel disease are not of such very rare occurrence as has been 
supposed by some, we must admit, that such attacks are evidently less fre. 
quent than they have been assumed to be by others, and it is hoped that further 
investigation may lead to a still more favorable aspect of it in this respect. 

[K— Page 92.] 

The communication of small pox to the foetus in utero is not of so rare 
occurrence as to render it necessary to adduce cases in proof of it ; but we 
introduce a few to illustrate its more common phenomena, and to show the 
relation between it and the influence of vaccination and of variola on the part 
of the mother, a relation by no means constant, as the sequel will show. 

In the Amer. Jour, of Med. Sci., five cases are reported of such commu- 
nication, in which the child was born with small pox, the mother remaining 
entirely free from the disease. 

The first was communicated by Dr. J. K. Mitchell (vol. vii. p. 555.) In 
this case, the child was born healthy, but exhibited symptoms of the disease 
three days after birth, and nine days after birth the pustules were in a state 
of complete maturity. 

The second case (vol. xi. p. 499) was communicated to the French 
Academy of Medicine in July, 1832, by M. Deneux. The child was covered 
at birth with confluent variolous pustules, in the eleventh or twelfth day of 
the eruption. 

The third case (vol. iv., new series, Oct. 1842, p. 485) occurred to Dr. C. 
Guoli, in a child born June 3, 1841, covered with pustules of variola. The 
pustules appeared at their height on the second day, and on the fifth day 
maturation began, but the child died on the ninth day after birth. 

The fourth case (vol. vi., new series, July, 1843, p. 210), reported and 
exhibited to the French Academy of Medicine in 1842, by M. Gerardin, was 
that of a child born five days previously with a full eruption of the disease 
in a state of suppuration. 

The fifth case (reported in vol. v., new series, Jan. 1843, p. 249) occurred 
in our city in 1842, in the practice of Dr. B. F. Josiin. The child had on its 
body at birth about 170 regularly formed pustules, apparently in the stage 
at which they would be found in ordinary cases about eight or ten days after 



APPENDIX. 349 

the attack. The child lived only a quarter of an hour. In this case, the 
infection was received by the mother just thirty days previous to the birth 
of the child. She was exposed but once to a single case, at the very com- 
mencement of the eruption, and for a single day. 

In the first case, the mother bore distinct marks at the time of the natural 
small pox with which she was affected in childhood. 

In the second case, the mother had been vaccinated, but had never had 
the small pox; and in the third case, the , mother had been successfully 
vaccinated when an infant. No mention is made of the protection of the 
mother in the fourth case. 

In the fifth case, the mother had been vaccinated in early childhood, and 
the operation was repeated on the day of exposure by Dr. Joslin himself, 
but without effect. 

M. Depaul met with a case of transmission of variola from a mother to 
her child, which had numerous pustules at birth, though the mother had 
visited a person with the disease a short time before without taking it. 
(Bullet, de Ther., Apr. 30, 1849.) 

A case also occurred in the Maternity Hospital in Paris, in which the 
face, scalp, and different parts of the child's head were covered with the 
pustules of small pox at birth, though the mother retained the marks of 
vaccination, and stated that she had never had the small pox. She had had 
no connexion with persons suffering under the disease, but only, about eight 
or ten days before, had gone to see a patient at La Pitie, near where lay 
another patient with the small pox. (London Lancet,Feb. 18, 1843, p. 741.) 

Dr. Mead has recorded an instance in which a woman was delivered of a 
dead child at the full time, covered with variolous pustules. She had 
formerly had the disease, and was attending her husband with it, when 
delivery took place. (Medical Works, chap, iv., p. 253.) 

Dr. Lebert exhibited to the Biological Society at Paris, a foetus about 
four months old, whose body was covered with pustules of variola. The 
mother had the disease slightly, and aborted during her convalescence. 
(Bulletin de Thtrap., Apr. 30, 1849.) 

Dr. King mentions a case (New York Jour. Med. and Surg., Apr. 1840, 
p. 292) which occurred in Paris, of the birth of a living child at seven months 
covered with an eruption of umbilicated pustules, the mother having entirely 
recovered, and presenting at the time of its birth no evidences of the erup- 
tion, except the red spots succeeding the scabs ; the child having been born 
twenty-one days since she was first attacked, or seventeen days after the 
appearance of the eruption. 

Dr. Luther V. Bell gives an instance of a lady who had small pox in the 
confluent form at the seventh month of pregnancy, and escaped without 
abortion ; but " at the expiration of her full term, was delivered of a healthy 
child, whose abdomen and thighs were marked with decided small pox 
pittings, and who was unsusceptible of the vaccine disease." (Notice of 
Essay on Small Pox, Varioloid, and Vaccination, Amer. Jour. Med, Sci, 
May, 1836.) 



350 APPENDIX. 

Van Swieten (quoted by Dr. Hosack) mentions a similar case of a child, 
born at full time, with pits of small pox, the disease having been communi- 
cated by transmission through its mother, who had herself long before gone 
through the disease. 

In one of Dr. Jenner's cases, referred to by our author, the mother, who 
had had small pox when a child, was exposed to it " a few days before 
confinement ;" the child was indisposed on the fifth day after birth, and the 
small pox appeared on the seventh day. There were but few pustules in 
this case, and they maturated completely. 

The cases of Dr. Jenner, originally published in the first volume of the 
Med. Chir. Transac. of London, and also the one by Dr. Mead, to which he 
alludes in that paper, may be found in the Amer. Jour. Med. Sci, vol. viii. 
p. 225. 

Cases of communication of the disease to the foetus in utero are also 
given by Dr. D. Hosack, with numerous references to other cases by differ- 
ent authors. (Medical Essays, vol. ii. p. Ill : also vol. iii. p. 470.) 

On the other hand, as our author remarks, the child sometimes escapes 
when the mother has the disease. A case is related in the Bulletin Gener. 
de T herapeutique (Feb. 1847, p. 143), in which a child born of a mother 
with small pox of the confluent form, and in an advanced period of desicca- 
tion, showed no marks of the disease whatever. 

It will be found on examination of the preceding and of other cases, that 
this communication has occurred after vaccination of the mother in infancy, 
and after her re-vaccination on the day of her exposure, and also after 
variola, both naturally and by inoculation. 

It also takes place when the mother is yet suffering from the disease, and 
after she has passed through it years previously, and when she herself 
escapes entirely. 

The foetus may be infected by absorption of the virus through the 
mother without her experiencing any effect from it, or transmitted directly 
by inoculation of the mother, and may be communicated any time from the 
fourth month (and perhaps earlier) to the full time. The foetus may be 
thrown off in three or four days after cessation of motion, or may be 
retained for three or four weeks. 

The child may be covered with eruption at birth, and this eruption may 
present itself in different stages of its progress in different cases, even up to 
the eleventh or twelfth day of the eruption, or may not appear until three 
or four, or even seven days after birth. It may also be born at full time 
with pits left by the disease some weeks previously. 

The child almost invariably falls a victim to the disease at once, or lingers 
for only a few days ; but has been born healthy at the full time, with marks 
of previous disease, and has survived, when the disease in a mild form has 
appeared after birth. 



APPENDIX. 351 



[ F.— Page 108. ] 

Other means besides those mentioned in the text have been used for 
preventing the pitting by the pustules of small pox, either by causing their 
abortion in the forming stage, or drying them up after they have maturated, 
and upon authority which would seem to render them worthy of some 
credit. 

As a general rule, the more recent the eruption, the more easily is it 
arrested. One writer thinks that the pustules can be arrested even after 
suppuration, and another fixes the period at which it can be done as late as 
the seventh day. 

Mercury has been used under different forms, both as a plaster and as a 
wash. M. Briquet employs (at the Hopital de la Charite, Paris) a mask 
composed of mercurial ointment, and solidified by means of the powder of 
starch or of fecula, which is renewed once or twice a day. A thick layer 
of it is spread with the finger over the forehead, cheeks, eyebrows, nose, 
lips, ears, &c, which causes abortion of the pustules, and prevents the 
swelling usually attendant upon the confluent form. {Bulletin Gener. de 
Th'rap. Med, et Chirurg., torn, xxxii. p. 60, Jan. 1847.) 

Prof. Bennett, of Edinburgh, also uses mercurial ointment thickened with 
starch (ty. Ungt. Hydrarg. 5j- Pulv. Amyli 3ij. m.), smeared over the face 
night and morning. (Monthly Jour. Med. Sci, Jan. 1850.) 

A compound mercurial plaster, known under the name of " plaster of 
vigo," of the French Pharmacopoeia, is a favorite application with some 
French physicians. 

If mercurial plaster is applied before the fifth day of the eruption, one of 
two things happens, — either the papules disappear by resolution, or they are 
changed into vesicles or into tubercles. The latter change is more rare, 
according to M. Briquet, and seldom takes place except on the face. 

When the dressing is removed, small, hard excrescences, insensible to the 
touch, are seen, which gradually fade, and disappear at the end of ten or 
twelve days, partly by resolution, and partly by desquamation, and without 
leaving any trace. The mercurial plaster must be be kept on eight to twelve 
days. (Report by M. Briquet to French, Acad. Med., Apr. 7, 1846, on a 
communication by M. Charcellay — Gaz. Med. de Paris, Avr. 11, 1846.) 

Ptyalism sometimes occurs from the application of mercurial plaster, a 
case of which is given in the Revue Medicale ; the result, however, proved 
eventually favorable. 

A solution of corrosive sublimate (one grain to £ vij. of distilled water, 
with 3 j. of laudanum), applied by means of compresses kept wet with it, is 
also said to produce very marked eifects in causing the disappearance of 
pustules, even after they have fully matured. 

Simple mercurial ointment is used much more frequently, both in this 
country and in Europe, than either the plaster of vigo or the wash of the 
bi-chloride, and is probably equally efficacious. It may be applied freely 



352 APPENDIX. 

with a brush or camel's hair pencil. Dr. Stewardson, of Philadelphia, speaks 
very favorably of its effects. (Amer. Jour. Med. Sci, Jan. 1843.) 

Baron Larrey communicated to the French Academy the use of gold leaf 
for this purpose by the Egyptians and Arabs ; but stated that he derived 
nearly as favorable results from repeatedly anointing the face with almond 
oil, an application which we have ourselves found grateful to the patient, 
and, to a certain extent, protective against cicatrices. 

M. Malapert recommends a solution of hydrate of potassa for this purpose^ 
which, he says, dries up the pustules without leaving any cicatrices or stains 
on the skin, but does not mention the strength of which it is to be used. 
(UAbeille Med, Juin, 1847.) 

Dr. Corrigan employs a coating of emplast. pi umbi, melted with oil of 
almonds, and laid on with a camel's hair pencil. (Dublin Quarterly Jour> 
Med., Aug. 1846, p. 245.) 

The exclusion of light is also thought to prevent pitting. See result of 
experiments by M. Serres, mentioned in Amer. Jour. Med. Sci, Oct. 1842, 
p. 459. 

Dr. Crawford, of Montreal, and Dr. Samuel Jackson, of Philadelphia, have 
succeeded in preventing pitting by the application of the tincture of iodine, 
each without the knowledge of the other, the former having published the 
first account of his trial of it. (Med. Examiner, Phila., Dec. 1846.) 

Sulphur ointment ( 3iss. to 3 ij. to § j. lard), rubbed lightly, three times a 
day, over the parts affeeted, has also been recommended as not inferior to 
mercurial preparations in preventing the suppuration of the pustules and the 
scars that usually follow them. (Gaz. Med. de Paris, Avr. 10, 1841, p. 
232.) 

Velpeau says that if the pustules are cauterized within the first two or 
three days, and even somewhat later, no marks will be left ; and Dr. Morton, 
of Philadelphia, says that he has confirmed the truth of this statement. 
Dr. Morton states that he has adopted with great success the plan of having 
the face frequently wet with spirits of hartshorn, which, he says, keeps down 
the inflammation, and prevents the pustules from becoming either large or 
irritable. (Notes to Mackintosh's Pract. Med.) 

M. Piorry recommends very highly the use of blisters for this purpose, 
and claims for them several advantages over other means. (Med. Chir. 
Rev., Jan. 1847 ; from Gaz. des Hopit.) 

Mr. Ranking suggests the use of collodion for this purpose, and the 
suggestion strikes us favorably ; but we have met no report of its applica- 
tion in this way. (Braiihwaite 's Retrosp., No. 19, p. 208.) 

A more extended. notice of some of the means mentioned in this summary 
may be found in the third number of the Journal last quoted, for January, 
1841.) 



APPENDIX. 353 



[ G.— Page 112. ] 

Others besides Sir Gilbert Blane have drawn the same inference that he 
did from the bills of mortality of London during the last century respecting 
the increase of mortality by the practice of inoculation, an increase which 
our author attributes solely to epidemic prevalence of the disease; and there 
are also additional facts which would seem to indicate that its effect has 
been equally positive during the present century. 

Mr. Marshall says of small pox in London, " It was more general, and 
more severe in its character, and caused greater mortality after the introduc- 
tion of inoculation, until the time of the introduction of vaccination." 
{Mortality of the Metropolis from 1629 to 1831, % John Marshall: London, 

1832.) 

According to the " Report on the Protective Powers of Vaccination" by 
Drs. Condie, Hewson, and Moore, of Philadelphia, variolous inoculation was 
prohibited in that city in 1811 ; and for four succeeding years, not a death 
from small pox was recorded. According to the same authority, for the 
period of sixteen years terminating with 1801, the proportion of deaths by 
small pox to the whole mortality was 73 in 1000. From 1807 to 1811, the 
proportion was 40 to 1000, during which time vaccination was practised; 
and from 1811 (when inoculation was abolished), the proportional mortality 
has been reduced to 18 in 1000. {Medical Examiner, Phila., Jan. 1847, 
p. 39.) 

Reference to the tables in the Appendix (B) will show that small pox 
has prevailed epidemically several times since 1811. 

Mr. Wylde says that " the superiority of vaccination over inoculation is 
shown by the fact that small pox mortality is highest in those provinces 
in which inoculation is most practised, and vaccination least." {Dr. West's 
Report— Brit and For. Med. Rev., Oct, 1845, p. 561.) 

Dr. Baron says {Life of Jenner, vol. i. p. 260) " the practice of inoculation, 
the greatest improvement ever introduced in the treatment of small pox, 
although beneficial to the person inoculated, has been detrimental to man- 
kind in general. It has kept up a constant source of noxious infection, 
which has more than counterbalanced the advantages of individual security." 

Sir Gilbert Blane says that the diffusion of small pox by inoculation was 
more strongly exemplified in the country than in London ; since there are 
many places where small pox was not known for twenty, thirty, and even 
forty years, in which at present scarcely an adult can be found who has not 
had it. In this case, however, we must make due allowance for epidemic 
influence, which has doubtless contributed very much to its more general 
diffusion. 

Besides, we cannot think that there would have been such unanimity in 
different countries in abolishing the practice, and, as in Great Britain, with 
the attachment of a heavy penalty to its exercise, had not the evidence in 
favor of such a measure been of the most decided character. 

We learn from Dr. Baron {Life of Jenner, vol. i. p. 234) that the practice 

23 



354 APPENDIX. 

was prohibited in Paris, by royal authority, in 1763, in consequence of its 
being found, on investigation by the police, that the infection was multiplied 
and diffused by its means. Also, that in Spain, where the practice was 
scarcely ever admitted, small pox has caused less mortality in proportion to 
the population than in any other country in Europe. Dr. B. also states 
(p. 235) that in 1768, the Empress Catharine of Russia submitted herself 
and her son Paul to inoculation, and that this spread the practice among the 
Russian nobility; and the disease prevailed so extensively, that Sir A. 
Crichton, subsequently the imperial physician, has stated that, previously to 
the adoption of vaccination, every seventh child born in Russia died annually 
of small pox. 

There seems also to be some discrepancy of opinion respecting the rate 
of mortality after inoculation. Our author states it to be, with ordinary 
precautions, one in five hundred. Though we perhaps might have hoped 
that improvement in the mode of conducting the operation, both in the 
preparatory and accompanying treatment, the selection of the proper season 
of the year. &c, might have led eventually to a diminished rate of mortality, 
still we fear it rarely descended to so low a figure. 

Dr. Jurin concluded, from an examination of the London bills of mor- 
tality for forty-two years, that of those who had been inoculated, one in fifty 
died. 

According to Mr. Shattuck ( Vital Statistics of Boston — Amer. Jour. Med. 
Sci., Apr. 1841), the deaths among those who were inoculated in that city 
between the years 1721 and 1792, amounting to nearly 23,000, varied from 
five in a thousand up to thirty in a thousand, the smallest mortality thus 
reaching one in two hundred of those inoculated. During the same series 
of years, the deaths by natural small pox ranged from the proportion of 95 
in 1000 to that of 344 in 1000 of those attacked. 

In addition to this, we must not overlook the permanent disfiguring of 
many, the danger of loss of eyesight, and also the liability to be followed 
by different chronic diseases. 

However great, therefore, may be our indebtedness to inoculation for the 
amount of life saved by it to mankind, and we freely acknowledge it to have 
been great, we cannot but feel that the practice can never be relieved from 
the objection of multiplying foci of contagion ; and, while we concede that 
its continued employment would doubtless have led to great improvement 
in the mode of conducting it, and to still more decided benefits from it, with 
probably diminished risk of communicating it beyond the individual operated 
upon, we cannot be too grateful for the substitution of another protective 
power, apparently equally efficacious in its results, and almost entirely free 
from the charge of the least danger in itself, either to the individual or to 
those about him. Not that we love inoculation less, but that we love 
vaccination more. 

At the same time we fully agree with our author that there are circum- 
stances which would warrant its adoption in special cases, and with proper 
restrictions, and that those mentioned by him come under this head ; and we 



APPENDIX. 355 

• 

could even add to the list. It is not denied that inoculation may be per- 
fectly sate, so far as the individual on whom it is performed is concerned, 
and that it may be a valuable test of his protection from casual variola ; but 
the fact that, however mild in itself, it may communicate the most malignant 
form of the disease to another, is one which renders it a dangerous agent, 
the use of which, independently of other reasons, should be restricted within 
narrow limits — and, indeed, prohibited altogether from the risk unavoidably 
attendant upon its general employment. 



[ H.— Page 171. ] 

The different views which have been entertained respecting the pathology 
of the dropsy following scarlet fever show that the subject, although it has 
received much attention, still requires further investigation. 

Some charge it upon the skin, whose functions as an emunctory are said, 
to be impaired, according to some, by the simple action of cold, and accord- 
ing to others, by the specific poison of the disease ; while another ascribes 
it to a sub-inflammation of the cellular texture originating in the eruption. 
Others again attribute it to general debility of the system. 

Dr. Golding Bird thinks that the sequelae of scarlatina are " almost all 
referrible to the retention of the nitrogenized. elements of urine in the 
blood," to which he attributes the tendency to the setting up of serous 
inflammation, especially of the pericardium, pleura, and arachnoid. 

Its connexion with an albuminous state of the urine, at least in a great 
majority of cases, has led many later pathologists to place the seat of it in 
the kidney; but even among those who have taken this view of its origin, 
there is discrepancy of opinion as to the exact part of the organ affected. 

Dr. George Johnson regards it as dependent upon an inflammation of the 
kidney, very similar to that state of the skin which results in desquamation 
of the cuticle. He calls it " acute desquamative nephritis." He says that 
this desquamative state of the secreting cells may exist some time before 
evidence of congestion of the kidneys appears. When this desquamation is 
excessive, the tubuli uriniferi may become choked with epithelium, and 
congestion may thus be produced, and this may be followed by inflanima* 
tion. {Med. Chir. Trans.^ vol. xxx. 1847.) Dr. West takes the same 
view of the active character of the inflammation. 

Dr. Schonlein is of the opinion that the exfoliation of the urinary epithe- 
lium is the predisposing cause of scarlatinal dropsy, and says that the 
patient is not safe so long as any of this deposit is found in the urine. 

Dr. James Miller considers the dropsy as " a part of the disease, or merely 
an evidence of another, but less obvious expression of the scarlatinal poison 
in the human body," and says that " it is no casual complication or sequel 
arising from undue exposure alone." He contends that the poison has a 
primary influence on the kidney, and affects it according to definite laws, 
showing itself then, as a general rule, on the fourteenth and twenty-first 
days, — and says that this ordinary period of the occurrence of renal symp- 



356 



APPENDIX. 



toms "is probably in accordance with the normal action of the scarlatinal 
poison still active on the kidney." The eruptive action is sometimes 
wanting, and to this form Dr. M. gives the name of " renal scarlatina, or 
scarlatina of the kidneys." 

Dr. Behrend describes two forms : — the first dependent upon congestion 
and inflammation of the kidneys {Hydrops nephriiicus) ; the second upon 
debility, or impoverished state of the blood (H. anccmicus). In the first 
form, he thinks that the dropsy is partly a direct result of the impediment to 
the eliminative process of the skin, and of the efforts of nature to restore 
this, and partly a consequence of the impediment to the excretion of urine 
by the kidneys. To the latter cause he attributes the effusions into the 
serous cavities ; while the dropsy of the cellular tissue seems to be a sequel 
of the renewed attempt at elimination by the skin. For a summary of his 
opinions and his conclusions, see Ranking' 's Abstract, No. 10, p. 28. 

Some support of the opinion which refers it to impaired function of the 
skin itself, at least occasionally, would seem to be afforded by an epidemic 
of scarlet fever in Berlin, in 1840, where, in a great majority of cases, the 
urine was not albuminous. 

On the other hand, the deposits of epithelial cells and " fibrinous casts" 
of the tubuli uriniferi found at times in the urine, would seem to favor the 
opinion of inflammation of the kidney as the primary form of the disease. 
This hyperaemia or inflammation of the kidneys is doubtless the cause of 
the albuminous urine, which may disappear as that condition of the organ is 
removed ; or it may become acute nephritis, with effusion of fibrin or pus ; 
or may pass into the confirmed albuminous nephritis of Rayer (Bright's 



.Hence, in fatal cases of scarlatinal dropsy, we find after death evidences 
either of simple congestion, or of inflammation in different stages of progress 
in different cases, from the earliest to the most advanced stage, and even 
abscesses in the kidney, and in protracted cases, the well known lesions of 
Bright's disease, instances of all which changes are on record. 

Dr. R. B. Todd considers the conditions of dropsy after scarlet fever to be 
— 1st, a particular state of the skin; 2d, a particular state of the kidney ; 
and 3d, a particular state of the blood ; and says that he does not think you 
get the dropsy fully developed without the concurrence of all three con- 
ditions ; that if one of them is absent, you may have a threatening of the 
dropsy, but the full result does not follow. (Lond. Med. Gaz., Feb. 1849.) 

Mr. J. W. Tripe acknowledges three varieties of scarlatinal dropsy : — 1. 
That in which the urine is not albuminous. 2. That in which it is albumi- 
nous, with subacute nephritis. 3. That in which the urine is albuminous, 
with acute nephritis ; or dropsy from debility, dropsy from renal derange- 
ment, and from disorganization. (Medical Times, Oct. 21, 1848.) 

Changes occur during this, as well as during many other acute diseases, 
which give rise to dropsy, especially in protracted cases, as is seen in 
phthisis, in convalescence from fever, malarial diseases, &c, when there is 
no reason to suppose that there is any affection of the kidney. But when 



APPENDIX. 351 

dropsy supervenes early, and particularly if it eomes on suddenly, and 
appears in the face first, and the patient shows no decided evidences of 
debility, there will be good reason to look to the kidneys as the cause. 

[ I.— Page 201. ] 

The treatment of the dropsy following- scarlet fever may be described 
under the two heads of -preventive and curative, the former, as our author 
remarks, always of course to be aimed at. 

Among preventive measures may be mentioned careful protection of 
patient from atmospheric changes, a regular diet, a free state of the bowels, 
and especially the frequent use of the tepid bath. The symptoms men- 
tioned in the text as precursory of effusion, must be carefully watched, and 
also the first indications of its appearance, which may generally be earliest 
detected in a puffy state of the eyelids, and an cedematous condition of the 
integuments of the cheeks, particularly about the lower part of the face. 

The treatment of the effusion, when it has once supervened, must depend 
upon the length of time since it appeared, its extent, its manner of appear- 
ance, whether slowly and gradually or rapidly, the constitution of the 
patient, the previous treatment, his condition at the time, and the nature of 
the prevailing epidemic. A careful attention to these several points, and 
especially to the condition of the patient at the time, will often enable us to 
decide upon the proper plan of treatment in a given case, and will also 
reconcile the apparently contradictory statements of those who recommend 
on the one hand an antiphlogistic course, and of those who, on the other 
hand, insist upon the necessity of tonics, each plan being proper under 
certain circumstances. 

The leading indications of treatment of this form of dropsy maybe stated 
to be — 1, to relieve the congestion of the kidneys; 2, to remove the accu- 
mulated fluid ; 3, to promote the action of the skin ; 4, if necessary, to 
support the tone of the system. 

The principal means to fulfil these indications are : 

1. Cupping, leeching, poultices, and fomentations; 

2. Hydragogue. cathartics, and mild diuretics; 

3. Diaphoretics, tepid bath, warm diluent drinks. 

4. Tonics of different kinds. 

In the early stage, and when there is a decidedly inflammatory state of 
the system, with a hot and dry skin, &c, and the patient is of a strong 
constitution, and the urine is highly charged with albumen, and the more 
so if it contains blood, depletion from the lumbar region by means of cups 
or leeches, followed by emollient poultices, may be called for; and in 
patients over six or eight years of age, it may even be necessary to take 
blood from the arm under such circumstances — but, as a general rule, the 
abstraction of blood, either locally or generally, may safely be dispensed 
with, and the application of poultices and fomentations be trusted. In this 
state of things, diuretics must be avoided, and the internal means restricted 



358 APPENDIX. 

to cathartics, diaphoretics, and emollient drinks. This course will be the 
more called for, if the effusion has taken place suddenly. 

In other cases, when the constitutional disturbance is slight, and the 
effusion has taken place gradually, and the patient is not enfeebled, hydra- 
gogue cathartics, with mild diuretics, and light diet, as mentioned by our 
author, will be all that is required. Among such cathartics, the combination 
of jalap and bi-tartrate of potassa is probably one of the best. Elaterium is 
also valuable, when more prompt action is necessary, and the effusion 
requires more immediate removal, and may be given in doses of ^ to I of a 
grain, every three or four hours. Castor oil may also be used, if these are 
tardy in their action. We have derived very decided benefit from the use 
of the apocynum cannabinum (Indian hemp) in cases of abundant effusion, 
when there was little or no febrile action, and have seen it act freely, both 
as a purgative and diuretic. 

In still milder cases, the iodide of potassium presents us with a good 
alterative and diuretic, and may be given alone, or in combination with some 
bitter infusion ; and when the system is much debilitated, and especially in 
those of strumous diathesis, iron constitutes a very valuable addition to our 
therapeutic means, and may be given in the form of iodide, citrate, or, as 
highly recommended by some, muriated tincture. In these cases, the diet 
should be generous and full, but carefully adapted to the state of the diges- 
tive organs, and the bowels kept in an open state. 

The acetate of lead has been recommended by some, after the active 
symptoms have subsided, when the kidneys are in a state of passive conges- 
tion, and a kind of serous haemorrhage is taking place. 

Diaphoretics are also used with advantage, and may be combined with 
diuretics, as the syrup of ipecac, with acetate of ammonia, and sweet spirits 
of nitre. 

To any and all these means, the tepid bath will be found a valuable 
auxiliary, and may be given every second or third evening, of the tempera- 
ture of 92° to 94° Fahr., and the child kept in it from twenty to thirty 
minutes. 

The cure is facilitated by keeping the patient in bed, and also by directing 
the constant use of flannel next to the skin. 



[ K.— Page 226. ] 

We have thought that our readers would be interested by a short abstract 
of some of the leading features of erysipelas in an epidemic form, as it has 
presented itself in different places in our country, remote from each other, 
during the past eight or nine years, and has been described by different 
writers under the different names of "Epidemic Erysipelas," "Erysipelatous 
Fever," as well as under the popular name of " Black Tongue," a name 
which one form of it has received in some parts of the Union. 

The earliest account of erysipelas in the form of an epidemic, within the 
period alluded to, which we have met, is that given by Drs. C. Hall and G. 



APPENDIX. 359 

J. Dexter (Amcr. Jour. Med. ScL, Jan. 1844) who describe it under the 
name of "erysipelatous fever," as it occurred in the northern section of 
Vermont and New Hampshire, in the years 1842-43. In this epidemic, 
there was great uniformity in the mode of attack for two or three months 
from its first appearance. After premonitory symptoms of pyrexia, with 
more or less sore throat, enlarged tonsils, and sub-maxillary glands, difficult 
deglutition, and sometimes painful respiration, attended with lassitude, pain 
in the back and limbs, frequent and depressed pulse, cold and clammy hands 
and feet, &c, &c, and generally at the end of twenty-four hours, there was a 
chill, sometimes a severe rigor, followed by general reaction, with frequent 
and bounding pulse; and in some instances, the skin was bathed with a 
copious acrid perspiration. In other cases, the attack came on when the 
patient was in apparent health, without any premonitory symptoms, with a 
sense of coldness, soon followed by severe chills. These were succeeded 
by pain in the head, stomach, abdomen, back, and joints, or some or all of 
these at the same time, followed in the course of twenty-four or thirty-six 
hours by the sore throat. The erysipelatous affection of the skin usually 
appeared about the third or fourth day ; and when it did appear, was not 
confined to any particular location. It was usually first observed on the 
side of the neck or face, presenting an acutely sensible and circumscribed 
red spot. 

In this epidemic, there was a marked connexion between the disease and 
puerperal peritonitis, and striking cases are given in which this latter disease 
was communicated to parturient females by physicians in attendance on 
cases of erysipelas. The puerperal disease proved very fatal. 

In one county in Vermont, of thirty cases of puerperal peritonitis which 
occurred, only one recovered ; and in Bath (N. H.), containing a population 
of 1500 or 1600, twenty mothers died from puerperal peritonitis, and about 
forty with erysipelas. 

Diaphoretics, anodynes, hot fomentations, and counter-irritants, were 
found the most useful means of treatment. In some cases with great heat, 
full, bounding, and frequent pulse, pain in the head, back, and limbs, and 
extreme thirst, prompt and efficient bleeding was the only remedy to be 
depended upon ; but it was necessary to employ it early. Different opinions 
were entertained respecting venesection by practitioners in the same neigh- 
borhood in this epidemic, but the general impression was against it, except 
in the class of cases just referred to. 

In the stage of collapse, quinine was given with much success, with 
diffusible stimuli; and when low muttering delirium supervened, opium, with 
tartrate of antimony, had a very excellent effect. 

The same form of erysipelas, with affection of the throat, occurred in 
Middlebury (Vermont) in the winter of 1841 and 1842, and has been 
described under the name of "epidemic erysipelatous fever" by Dr. J. A. 
Allen in the Boston Med. and Surg. Jour., vol. xxix. 1844. The throat was 
uniformly found inflamed, and the tonsils swollen, sometimes to such an 
extent in a few hours that deglutition could only be performed with 



360 APPENDIX. 

extreme difficulty. The tongue became so much enlarged in some cases as 
to fill the mouth, and prevent the passage of anything to the stomach. But 
this was rather a rare occurrence. In the course of a day or two, the 
disorder of the throat and mouth became mitigated, or entirely gone ; and in 
proportion as the local affection diminished, the face, scalp, or side of the 
neck became swollen, painful, hot, and vesicated, presenting the unequivocal 
characteristics of erysipelas. The local disease in some cases attacked the 
brain, in others the lungs, in other cases the abdominal viscera, and occa- 
sionally the soles of the feet, ankles, or palms of the hands. 

The number of cases in Middlebury was estimated at about six hundred 
and fifty, with a population of about 3,200. A few cases occurred in 
November and December, 1841 ; but by far the largest number occurred in 
the next two months. Thirty-four deaths were caused by it between the 
first of January and the latter part of May, 1842. Puerperal peritonitis 
assumed an erysipelatous character, and added to the mortality, both in this 
epidemic, and in an epidemic of erysipelas in the same town in 1825-6; 
five cases occurring in the former, and all fatal, and seventeen in the latter, 
of which only two survived. 

In 1826, there were not less than sixty cases of parturition in Burlington, 
and in 1842, not less than twenty. " Hence," adds Dr. A., " at each time of 
the prevalence of the epidemic erysipelas, one fourth of the obstetric cases had 
the child-bed fever." In the winter of 1841-42, at Crown Point (N. Y.), 
two physicians had over sixty cases of delivery, and of these, fifteen or 
sixteen had puerperal fever, and died. 

Venesection was found of the greatest value in this epidemic, when there 
was great vascular action, or congestion of any vital organ ; but was prac- 
tised in only a minority of the cases. Diaphoretics, with external warmth , 
were found useful, and among the most valuable means for acting on the 
skin, was pulvis antimonialis. Dr. A. derived no particular benefit from the 
use of calomel as an alterative. 

The same fever also prevailed extensively at Moriah (N. Y.), a town 
about twenty miles from Middlebury, in 1842, at the time it was most rife 
at this latter place, and it was estimated that nearly a thousand cases 
occurred there. It also prevailed in the neighboring towns in the winter of 
1842-43. From what Dr. A. observed, he deduced the conclusion that 
" when it has once expended itself in a place, village, or neighborhood, it will 
not recur again in the same place for a series of years ;" also, " that those 
individuals who have had it at one epidemic period are exempt from its influ- 
ence at its next occurrence." 

Dr. George Sutton, of Aurora, Indiana, published ( Western Lancet, Nov. 
1843) an account of the disease as it appeared in Ripley and Dearborn 
counties of that State, in 1842-43, under the name of "Epidemic Erysipelas, 
known by the popular name of 'Black Tongue.'" The epidemic assumed 
different characters, one of which was an erysipelas, connected with 
cynanche tonsillaris, or swelling of some of the lymphatic glands. Another 
was a typhoid pneumonia, sometimes connected with swelling of the axillary 



APPENDIX. 361 

glands. He aaya the premonitory symptoms in each disease were alike, 
and the character of the fever the same; and that one form of disease often 
changed into the other, and the two forms frequently attacked different 
members of the same family at the same time. The attack was always 
ushered in by a chill, lasting in some cases four or five hours, after premo- 
nitory symptoms for two or three days. " This was followed by a high 
fever, swelling of the tonsils, submaxillary, parotid, and lymphatic glands of 
the neck ; neuralgic pains, darting over the side of the neck and head, 
frequently following the temporal artery ; the tongue, covered at first with 
a thick, brown coat, soon became swollen, and often very dark in the centre ; 
deglutition frequently very difficult ; pulse generally very full, though easily 
compressed ; skin at first hot and dry, becoming moist, and continuing so 
after venesection. Sometimes the mild form had only the appearance of 
cvnanche tonsillaris. But in the more malignant form, when the throat was 
affected, after the above symptoms had continued for two or three days, 
and sometimes from the very commencement, the pharynx became of a 
dark purple color ; this color generally spread over the palate, tongue, and 
sides of the cheeks, the tongue becoming very much swollen, assuming a 
blackish brown color; deglutition in many cases was almost impossible. 
In most of these cases, an erysipelas would commence at the angle of the 
mouth or nose, and spread over the face and head, with all the symptoms 
peculiar to that disease." "In nearly every case," he says, "the throat 
became well, ichile the erysipelas was spreading over the skin." The disease 
seemed sometimes to commence in the frontal sinuses and antrum. There 
would then be a discharge of large quantities of water from the nose, and the 
face would swell so much as to close the eyelids. These symptoms gradu- 
ally continued until an erysipelas made its appearance, or there was a copious 
discharge of bloody mucus from the nose. In a case of this kind seen by 
Dr. Sutton, the neck was enormously swollen from the left ear down to the 
sternum, without any redness of the skin, and but little inflammation of the 
pharynx; this swelling rapidly subsided, and was followed by a profound 
coma that terminated in death. "In a number of cases, the inguinal 
glands were the seat of the disease, becoming very much inflamed, and 
an erysipelas first making its appearance there, and spreading over the 
abdomen." 

The treatment of the epidemic at the commencement of the attack was 
strictly antiphlogistic, bearing in mind the tendency it had to assume a 
typhoid character. Blood was drawn from a large orifice, with the patient 
in the upright position, until a decided impression was made on the system, 
and this w-as generally produced by taking a few ounces in pneumonia. 
When the throat was attacked, emetics, followed by mercurial cathartics, 
nauseants, blisters, liniments, and sinapisms to the throat, pediluvia, acidu- 
lated and pepper gargles, scarifying the tonsils, and when the throat was 
ulcerated, the application of a solution of nitrate of silver, was the course 
generally adopted, and in a large number of cases, the bleeding, the emetic, 
and the mercurial cathartic cut short the disease at once. Great caution 



362 APPENDIX. 

was required in giving mercury, care being exercised to avoid its specific 
effect. 

When the erysipelas appeared on the skin, alterative doses of calomel 
and ipecac, (carefully avoiding ptyalism), followed by saline cathartics and 
antimonial diaphoretics, were used in the robust ; and wine whey, carbonate 
of ammonia, Dover's powder with calomel, followed by gentle laxatives, 
when the disease assumed a typhoid character. As a local application to 
the erysipelas, a solution of the sulphate of copper, and also of the sulphate 
of iron, appeared to produce good effects ; and when the skin was not 
blistered, the spirits of turpentine answered very well. 

The fatality of the disease varied very much in different places, in some 
townships being very great. In several places it was accompanied by 
puerperal fever, which was also very fatal. 

Dr. Sutton was unable to give any statistics of its mortality, but says 
that it was generally considered by the oldest inhabitants to have been the 
most fatal epidemic within their memory that has visited our country, not 
even excepting the cholera. (Quoted in Amer. edit, of Nunneley on Erysi- 
pelas ; and also in Amer. Jour. Med. Sci, Jan. 1844, p. 247.) 

In an account of "epidemic erysipelas" at Michigan City (Indiana), in 
1843-44, given by Dr. Meeker (Illinois Med. and Surg. Jour., June, 1844, 
quoted by Amer. Jour. Med. Scl, July, 1844, p. 273), of sixty cases, one 
half were fatal. In this epidemic, the skin alone was affected in some 
cases, with the mucous membrane of the fauces ; and in other cases, the 
internal organs became inflamed, without its making its appearance upon 
the surface at all. It attacked nearly all puerperal females, not more than 
one in ten escaping. The rate of mortality in these cases is not stated. 

In an epidemic which occurred in Petersburgh (Virg.), during the winter 
and spring of 1844-45, described by Dr. Peebles under the name of 
"epidemic erysipelas" (Amer. Jour. Med. Sci, Jan. 1846), to which we 
have already alluded in the body of the work, " the disease presented three 
distinct varieties, or grades of violence. First, simple erysipelatous fever 
characterized by the peculiar throat affection, accompanied by enlargement 
and tenderness of the glands of the neck, and stiffness of the cervical 
muscles. Secondly, to these symptoms, usually coming on with a chill of 
greater or less violence, there was after the third or fourth day superadded 
the external erysipelatous inflammation, generally on the face and scalp. 
Thirdly, the disease assuming totally different features, much increased in 
severity and danger, was first manifested in the form of severe inflammatory 
action located in some important internal organ, which symptom was only 
ultimately relieved by the appearance of the cutaneous inflammation." The 
internal disease was always located in the mucous membranes, and was 
liable to seize that in the lungs, including the larynx, and the minute 
bronchial ramifications, that of the stomach and bowels, and of the bladder 
and urethra. 

Dr. Peebles states that it was invariably the case in his practice in this 
epidemic, as was also true in that described by Dr. Allen, that the symptoms 



APPENDIX. 363 

of the intern: 1 .! affection were relieved or were speedily removed by the 
appearance of inflammation on the surface, which invariably took place in 
all the most severe and malignant cases of the disease. 

Dr. Daniel Drake also gives a general account of a form of erysipelas 
known under the name of " Black Tongue," which prevailed in Mississippi 
and Missouri in 1844, founded entirely on verbal accounts of the disease 
derived from different practitioners in those states with whom he held 
personal communication. He says that it affects both whites and blacks, 
the latter perhaps more frequently and fatally than the former, and occurs 
in both winter and summer. In some cases, the local, and in others, the 
constitutional symptoms appeared first, but the fever has always preceded 
the cutaneous inflammation. In some cases, the stomach instead of the 
throat was the seat of the disease. As the erysipelas appeared, the angina 
generally ceased. In some eases, the tongue was so swollen and inflamed 
as to make glossitis the prominent part of the disease. Dr. Drake considers 
the disease to be a compound of erysipelas and scarlatina, though he does 
not regard such a conclusion as established. The brain, lungs, and stomach 
and bowels, were severally the subject of the disease in different cases. 

The lancet was employed with advantage in the early stage of the 
disease, especially when the brain, or lungs, or any of the abdominal viscera 
were attacked. Cathartics were generally employed, but not in large 
quantities, and copious purging was not on the whole beneficial. When 
exhaustion came on, as was the case in many instances after the first few 
days, diffusible stimulants, with tonics and nutrients, were required, and 
were found useful, especially in extensive suppuration, and with a tendency 
to gangrene. Various local applications were used by different practitioners, 
and all with an equally equivocal benefit. (Western Jour, of Med. and 
Surg., Oct. 1844; quoted in Bulletin of Medical Science, Nov. 1844.) 

The same disease, as it occurred in Warrenton (Miss.), in March, 1844, is 
described under the same name by Dr. W. R. Puckett of that place, and 
presented the same general characteristics as the form which prevailed 
elsewhere, presenting similarly great diversity in mode of invasion as well 
as in its points of attack. (New Orleans Med. Jour. ; quoted also in Bull. 
Med. Scl, Nov. 1844.) 

This disease also prevailed in Delaware county, Pennsylvania, during the 
spring and early part of summer of 1844, in a severe form, and is described 
under the name of " epidemic erysipelas," by Dr. Jesse Young. It generally 
came on with the usual symptoms of catarrh. The erysipelatous inflamma- 
tion appeared on the surface at the end of three or four, and frequently 
seven and eight days ' after the commencement of the constitutional symp- 
toms, but without any regularity in this respect. When it came out in 
patches for a short time, and then receded, which it was very apt to do, the 
patients rarely recovered, no treatment having any effect in such cases. 
When the efflorescence came out and remained on the surface, the patient 
generally recovered at the end of from one week to three or four. The 



364 APPENDIX. 

efflorescence appeared often on the head and face, but frequently on the 
extremities, or some part of the body. 

The plan of treatment found most efficacious consisted of emetics of 
ipecac, and ant. tart, combined ; afterwards cathartics of calomel, followed 
by jalap or some other purgative, in a few hours ; and after free evacuations, 
mild diluent drinks of different herb teas. The lancet was freely used in 
the earliest cases, but with unfavorable effect ; and all agreed, after more 
familiarity with the disease, that " venesection was a dangerous, or at least 
a very uncertain, expedient." 

When the disease did not receive early attention, the patient sank from 
day to day, until great prostration ensued, and sometimes the erysipelatous 
surface was attacked with gangrene, with extensive sloughing. In such 
cases, tonics, with powerful stimulants, were required. 

The writer states that "quite an unusual number of deaths occurred," 
but most of them in the early part of the epidemic, but gives no statistics. 
{Medical Examiner, Phila., Sept. 7, 1844 ; quoted by Amer. Jour. Med. 
Sci, Oct. 1844, p. 546.) 

Dr. Lovelace describes the " black tongue" as it appeared in Vicksburg 
(Miss.), when it was first observed in March, 1844. He and his partner 
saw forty-two cases, of which six terminated fatally. Blood-letting did 
not answer in that epidemic. (New Orleans Med. and Surg. Jour., Sept. 
1846, p. 190.) 

Dr. A. M. Keller gives cases (Western Jour. Med. and Surg., Oct. 1845) 
of " erysipelatous laryngitis" or " black tongue," occurring in Courtland, 
Alabama. 

Dr. S. Glisson also, in a letter to the editor of the New York Journal of 
Medicine, dated Livingston, Michigan, June 20, 1847, speaks of a form of 
"malignant erysipelas, commonly called Black Tongue," which, he says, 
had been lately observed in the neighborhood of that place. He says " the 
black appearance of the tongue has not been noticed more than once, per- 
haps, out of ten cases;" but that it looked more as if it had been boiled. 
There was also very great tumefaction of the face and scalp, and also of 
the fauces, palate, tongue, &c. He says the disease proved fatal in many 
cases, but gives no statistics. 

The treatment which appeared most successful was the stimulating and 
diaphoretic. The antiphlogistic made but little impression, and the patient 
soon fell into a typhoid state, which rendered stimulants necessary. (New 
York Jour. Med., July, 1847, p. 127.) 

Dr. H. N. Bennett has given a description (New York Jour. Med., May, 
1848) of an " epidemic erysipelatous fever," as it occurred in Bethel, Fair- 
field county (Conn.), from the middle of Nov. 1837 to the middle of March, 
1848. The disease resembled very strongly, as Dr. B. remarks, in its 
general symptoms, local lesions, and the mortality attending it, the charac- 
ters which it has presented in other portions of the country. Great 
uniformity existed in the premonitory symptoms. A very constant, and Dr. 



APPENDIX. 3G5 

B. thinks, a uniform seat of inflammation, was the throat, presenting- different 
appearances in different individuals. " In all cases without exception, there 
was more or less tenderness and swelling of either the sub-maxillary, 
parotid, or lymphatic glands of the neck, as well as of the tonsils; and the 
uvula was almost as universally elongated." The erysipelatous efflorescence 
occurred in one sixth of the cases. 

The ages of the patients, in fifty-nine cases of which a table is given, 
varied from eight to seventy-five years, and the duration of the disease from 
throe days to as many months, including the milder cases of angina on one 
extreme, and the cases of pectoral abscess on the other. 

In this epidemic, the serous membranes were a frequent seat of the 
disease, especially the pleura and peritoneum. 

Dr. B. inclines to the opinion of the contagious nature of the disease, 
with certain restrictions, but thinks that the evidence of fomitic contagion, 
with reference to the puerperal cases, is very meagre. 

In the treatment of the anginose cases of the disease, Dr. B. commenced 
wilh an emetic of tartarized antimony, taken with a strong decoction of 
eupatorium. This was followed by a blister to the neck, and sometimes a 
strong solution of nitrate of silver directly to the inflamed mucous surfaces. 
In more malignant cases, he depended mainly upon bark, with serpentine 
and mild laxatives during the first stages, and the more powerful stimulants 
afterwards. He abandoned all external remedies except cooling lotions. 



[ L.— Page 287. ] 

That the ground taken by the earliest vaccinators, and among them the 
immortal Jenner himself, that vaccination is a perfect protection of the 
system through life against variola cannot now be maintained to the letter, 
is almost universally acknowledged. The extent of the protection afforded 
by this precious gift to man, the causes which interfere with its entire 
protective power, and the means necessary to remove the obstacles in the 
way of such protection, are not so well agreed upon. It must be conceded 
that cases of a modified form of variola are occurring, and apparently with 
somewhat increasing frequency, in those supposed to be protected by the 
process of vaccination ; but it is consoling to notice, that even with this 
increased frequency of attack, there is a mildness which divests it of very 
much of its dread, and a mortality which, compared with that in the 
unprotected, is slight — and there is much reason to believe that the fatality 
does not increase in proportion to the frequency of attacks, and that the 
rate will be found not to reach that of seven per cent., as furnished by the 
statistics of the London Small Pox Hospital. 

We have collected statistics bearing on this point from different and 
distant sources, which would serve to prove that, at least under certain 
circumstances, and, perhaps, we may with propriety say, as a general rule, 
this is the case. 

At the same time we would premise, that instances are recorded where 



366 APPENDIX. 

the mortality has reached a higher ratio ; but they are so few in number, 
that their very rarity affords fair ground for the question whether some 
peculiar circumstances may not have operated in the case. 

The replies received by the Committee of the Prov. Med. and Surg. 
Association would seem to place the matter in a different light. The only 
two statements at all conflicting with the general favorable tenor of these 
replies was that of one gentleman, who stated that of nearly one hundred 
cases attended by him the previous year, one half were after vaccination ; 
and of another, who reports that of eighty cases of small pox, sixty Or 
sixty-one had been vaccinated. In the latter instance, it is stated that the 
majority of the vaccinations had been performed by a superannuated excise 
officer, and the only fatal case that occurred had been vaccinated by this 
man, and by him pronounced safe. 

This Committee say " the total number of deaths reported by all the 
gentlemen who have answered our questions, throughout nearly the whole of 
England, amount to very little above thirty. They say also, that they have 
the testimony of those who have been engaged in the practice of vaccination 
from its commencement down to the time of their report (1839), who have 
never met with an instance of this kind. One gentleman who began in 1802, 
and had vaccinated from six to seven thousand, had not met with more 
than ten or twelve failures, and not one death. Another who commenced in 
1805, under the immediate inspection of Dr. Jenner himself, and who con- 
tinued to practise it up to 1838, never saw a death from small pox after 
vaccination. Dr. Henry Jenner, the nephew of the distinguished Dr. J., 
met with the same result. Another who had vaccinated extensively and 
gratuitously for twenty-four years, had not seen twenty cases of modified 
small pox, and not a death after vaccination. 

Mr. Ceely, of Aylesbury, reported that there were twenty-eight deaths by 
small pox last year in that place (1838), but not one occurred after vacci- 
nation. 

Another practitioner of vaccination for thirty- two years stated that, 
though small pox had prevailed the previous winter (1838) to a great 
extent, and was very fatal, he had not seen in proportion more cases of that 
disease after vaccination than of small pox after small pox. 

One physician, who began to vaccinate in 1798, stated that "very few" 
cases of small pox had followed vaccination in his experience, and that in 
most of the instances of the kind which he had heard of, the vaccination 
had either been interrupted in its progress, or performed by a non-medical 
person. He gives one melancholy instance in which a family had been 
" cut " by an itinerant quack, most of whom afterwards caught the small 
pox and died. He adds, that he had never seen a fatal case of small pox 
after vaccination, but had seen five cases of small pox after small pox. 

Two physicians, father and son, could altogether enumerate about twenty- 
four persons in whom small pox had followed vaccination during the whole 
of their professional lives, and of these, they themselves only saw nine. 

Another, who had been settled in practice thirty-one years, had had two 



ArFENDIX. 367 

cases of small pox after vaccination, both very mild and modified; and had 
had three eases of secondary small pox, two after inoculation, one of which 
proved fetal. 

At the Royal Military Asylum (England), 1406 children were admitted 
from 1819 to 1837, and all were vaccinated, whether previously vaccinated or 
not : and among these, one case of small pox or varioloid eruption happened 
in 1826. During a part of this time, small pox had been very prevalent and 
fatal among the poor. 

Of one hundred and fourteen cases after reputed vaccination in 1837, 
mentioned by Mr. Dodd, the Secretary of the Committee, only two were 
fatal. He never saw a case of small pox in a patient he had vaccinated, 
after a practice of ten years. 

According to the report of the National Establishment, eighty-three 
thousand six hundred and forty-six persons were vaccinated from 1825 to 

1832, and among these, only two deaths by small pox occurred, and one of 
these of a very doubtful nature. 

In the Royal Military Asylum at Chelsea, from August, 1803, to August, 

1833, those reported to have had small pox before admission were 2532 
(1887 boys, 645 girls) ; the number reported to have been vaccinated before 
admission was 3060 (2498 boys, 562 girls). Those who had small pox 
after reputed small pox were 26 (15 boys and 11 girls). The cases of 
small pox after reputed vaccination were 24 ; 19 boys and 5 girls. The 
whole number vaccinated at the asylum subsequently to admission was 
628; 460 boys and 168 girls. Of the whole, only two boys and one girl 
caught the small pox. Five deaths occurred ; four boys and one girl. Of 
these five children, three had the disease after reputed small pox, and two 
had neither been vaccinated nor had undergone the small pox before. In 
this instance, it will be seen that not a single death occurred after vaccina- 
tion, while three out of the five fatal cases were after small pox. 

Dr. Labatt, who, from the commencement, paid very great attention to 
the character of vaccination, and watched it with care, states that, from his 
observation, " the reputed failures have almost invariably originated either 
from want of skill or inattention of practitioners, from inoculation having 
been performed by unprofessional persons, or the extreme inattention of 
parents and others in not showing children at the several stages of the 
affection." He adds that, during an extensive practice of thirty-six years 
and upwards, he has not witnessed a single case of death from small pox 
after regular vaccination, and not more than ten cases in which small pox 
occurred in persons who previously had cow pox. 

In one of the largest institutions of Dublin (name not mentioned), the 
average number of whose inmates was between 2000 and 3000, up to the 
latter part of March, 1839, thirty-eight cases of small pox had occurred, and 
but a single case of that disease after vaccination, and that in a child said 
to have been vaccinated two years before in Liverpool, but on whose arm 
there was no trace of cow pox. 

The Committee of the Prov. Med. and Surg. Associat. conclude their 



368 APPENDIX. 

remarks on the continued protective power of cow pox by saying, " we hold 
it to be proved beyond all doubt, that the same laws which govern human 
small pox apply, ' mutatis mutandis,' to cow small pox." They deny that 
the cow small pox, duly and efficiently communicated to man, loses its 
influence by time. They remark that in the midst of such conflicting 
evidence, there is no other way than to recur to first principles, and inquire 
whether the lymph has been pure, and the development of the affection 
regular and complete, and the state of the patient such as to present no 
impediment to the regular course of the affection. A patient should never 
be considered safe, nor has vaccination been duly performed, unless all 
these things have been attended to,/md it is doubtless to the neglect of 
such attention that many failures are to be attributed. They add, " all cases 
of reputed vaccination, unless they have passed under review of a competent 
judge, who has witnessed the different stages of the affection, should be 
considered as no vaccination at ale." 

Mr. Thomas Hunt, of London, says, " in a large medical practice in 
Hertfordshire, embracing the majority of the population of thirty square 
miles, only one case of small pox occurred in seven years — from 1812 to 
1819, and that not after vaccination. At that time, medical men only 
vaccinated." " Dr. Walker, who vaccinated with his own hands half a 
million of human beings, and pronounced them all secure for life, after 
being engaged in vaccinating for thirty years, saw but two cases of small 
pox after vaccination, and these, he says, were two lives saved; for they 
only out of two large families were vaccinated, and the rest all perished 
with the disease." (On Protective Power of Vaccination — Prov. Med. and 
Surg. Jour., Sept 18, 1850.) 

Mr. Newnham says, " instances of perfect security after vaccination may 
be multiplied indefinitely : the instances of failure are few in comparison with 
the numbers vaccinated : and the cases of death from really modified small 
pox, by previous effective vaccination, are, upon the gross scale, inappre- 
ciably few." (Prov. Med. and Surg. Jour., May 1, 1850.) 

We have thus far confined ourselves to statistics furnished by English 
practitioners, for the purpose of a more fair comparison with those furnished 
by our author — but have reason to believe that those furnished by conti- 
nental practitioners, as well as those of our country, will afford a corres- 
ponding low state of mortality after vaccination. 

From a table prepared by M. Villeneuve, Reporter of a Commission 
appointed by the Academy of Medicine at Paris, it appears that of 365 cases 
of confirmed small pox, in persons who had been at some previous period 
successfully vaccinated, there were only eight that proved fatal — about 1 
in 45 or 46. (Amer. Jour. Med. Sci, July, 1841.) 

M. Bousquet has collected the statistics of thirty-one epidemics in different 
parts of France, from 18J6 to 1841 inclusive, which he has presented in a 
tabular form, and from these we learn, that of 6,071 persons attacked with 
variola after vaccination, only sixty-three died, or about one per cent. ; 
while during the same series of years, of thirty-four cases of secondary 



APPENDIX. 369 

small pox, five proved fatal. (Nouveau Traite de la Vaccine, Paris, 1848.) 
It must be remembered that these results occurred during epidemic preva- 
lence, a condition necessary for the proper settlement of the question. The 
same author has also collected, with great industry, extended statistics 
on this subject from other countries, presenting evidence of the same 
general character, to which we must refer our reader, without transferring 
them to our pages. 

Dr. Luther V. Bell, of Deny (N. H.), states, as the result of his own 
experience, that no instance of death, when vaccination was performed prior 
to exposure, had occurred in more than two hundred cases of variolous 
disease attended by him, and a very large number of other cases he had 
witnessed. (Amer. Jour. Med. Sci, May, 1836.) 

According to the Report of Drs. Mitchell and Bell, who had charge of 
the Small Pox Hospital in Philadelphia, forty-seven cases occurred there in 
1823-24, in persons who had been previously affected by vaccination, and 
not one proved fatal. Eight cases occurred in persons previously affected 
with small pox, of whom four died. (Quoted by Dr. Chapman — Eruptive 
Fevers, p. 91.) 

A committee of the Philadelphia Medical Society, appointed to collect 
facts upon the subject of small pox, say, " We may, without the least want 
of candor, come to the conclusion, that only one death from small pox after 
vaccination has occurred in Philadelphia during the year 1827, among eighty 
thousand vaccinated persons, and during the prevalence of a most malignant 
and mortal small pox ; while several individuals have lost their lives by 
small pox, after they had already gone once through the disease." (Quoted 
by Dr. Morton — Notes on Mackintosh'' s Practice of Medicine, 4th Amer. 
Edit., p. 174.) 

We might multiply statements from still other sources of the same 
general character with those already quoted, but will not enter into further 
detail, as we feel that sufficient has been brought forward to console us 
with the belief that the rate of mortality by small pox after vaccination, at 
least in countries at large, falls short of that shown by the statistics of the 
Small Pox Hospital of London to be true with regard to that institution — 
and we cannot but hope that the high rate of seven per cent, may be con- 
fined to limited sections of country, and perhaps to hospitals alone, and thus 
depend upon circumstances more or less local in their character. 

As these sheets were on the eve of going to press, we received from Dr. 
Gregory the following table, giving the statistics of the London Small Pox 
Hospital for the ten years from 1841 to 1850 inclusive, which, as will be 
seen, fully sustain the rate of mortality by small pox after vaccination in 
that institution, as already stated by him. 



24 



370 



APPENDIX. 



Table exhibiting the total number of persons having small pox, admitted 
into the Small Pox Hospital of London, in the years from 1841 to 1850, 
inclusive, with the proportion of cases admitted after vaccination, and the 
mortality in each class respectively. 

























CS to 












i 




,£3 


Total of 




» 




A 






Total ad- 




d 


Total of 






persons un- 




~_ 


Percentage 

of Ad- 

missions 

after Vac- 
cination 

with Scars. 


** > 

tc © 




YEARS. 


missions of 
persons 
having 

Small Pox. 




0) 

- 

o 


persons 
Vaccinated 

with 
Cicatrices. 




Q 
o 

hi 


protected, 

including 

the 

Vaccinated 
without 




Q 
c 
to 

- 


.5 e. 




c 

ESC 

c 
c 
e 

3 








o 
u 




A 


C 

SB 


Scars. 


03 
A 


S3 
<» 

u 




ODD 


V. 

A 






"5 












"eS 






£*c 


c 






<o 


Z 




CD 


V 




<D 


V 




<a ed 


c 


1841 


342 


74 


Ph 




10 




191 


n 


Pm 




2 


P 
1 


151 


64 




44 


1842 


141 


34 




62 


4 




79 


30 




44 


1 





1843 


149 


27 




69 







80 


27 




46 


2 





1844 


643 


151 




312 


24 




331 


127 




50 


3 


2 


1845 


367 


79 




217 


13 




150 


66 




60 


3 





1846 


147 


29 




77 


5 




70 


24 




52 


2 





1847 


450 


81 




230 


17 




220 


64 




51 


8 


3 


.1848 


686 


168 




365 


38 




321 


130 




53 


4 


2 


1849 


190 


33 




115 


11 




75 


22 




60 


4 





1850 


307 


58 
734 


22 


155 


8 




152 


50 
604 


3G 


50 
51 


1 
30* 




8 


Total in 


3422 


1753* 


130 


7 


1669t 


10 years. 



























[M^— Page 291.] 

We feel that the propriety, if not the duty, of re-vaccination is now so 
generally acknowledged as perhaps to render it unnecessary for us to 
adduce evidence in favor of the practice. But as the views of some on the 
subject may not be so fully established, and as others may feel interested in 
an examination of the evidence by which it is supported, we have concluded 
to devote a short space to it. 

Some of the earliest, and at the same time most conclusive testimony in 
its favor, is furnished by its results in the Wirtemberg, Hanoverian, Bava- 
rian, and especially in the Prussian armies. Our limits will not permit us 
even to give a summary of the figures on which the results are founded, 



* Nearly the whole of these 1753 cases were above the age of fifteen years. 

t Many of the persons alleging to have been vaccinated, but not showing 
cicatrices, were doubtless duly vaccinated, but to distinguish such cases from the 
others was impossible. 

% N. B. The persons professing to have had small pox at some former period, 
sometimes announced themselves to have been inoculated, sometimes to have had 
the casual small pox, but in no one instance was there any corroborating evidence 
of the truth of the statement. These cases, therefore, are included in the third 
column of " Persons Unprotected" 



APPENDIX. 371 

and we can only transfer to our pages some of their most striking features 
and items. 

Re-vaccination was first commenced systematically in the Prussian 
armies in the year 1833, after having been practised in the Wirtemberg 
army and among smaller bodies of men for several years previously, and 
recommended by several leading practitioners, and has been continued in 
that and in several other armies, and also among large bodies of civilians, 
from that time to the present. The following are among the results : 

In Wirtemberg, but one case of variola occurred in five years among 
14,384 re-vaccinated soldiers, and three only among 26,864 re-vaccinated 
civilians. 

Not a single case of small pox occurred among those who had been 
re-vaccinated in the Prussian army in 1836, 1837, or 1839. But three 
deaths by this disease occurred in all the military hospitals of Prussia in 
1841, and of these, one was in a person not vaccinated on entering the 
army, because it had been done shortly before ; a second in a recruit who 
had not been re-vaccinated ; and the third in an officer, who had been 
re-vaccinated some years before, but without success. 

In 1834, two deaths are recorded of those who had been re-vaccinated 
with effect in the Prussian army, and one in 1843. In 1849, but one case 
was fatal, and this was in a recruit, vaccinated when a child, and who had 
not yet been re-vaccinated. 

During an epidemic of small pox in Copenhagen in 1828 to 1830, and 
also a very severe one in 1832, and another in 1835, not a single instance 
of variolous or varioloid disease was observed among any who had been 
re-vaccinated. 

In the Danish army, of those who were successfully re-vaccinated in 
1838, not one was attacked with small pox. 

In an epidemic of variola at Heidelburgh in 1843 and 1844, described by 
Dr. Hoefle, of all those attacked, not a single one had been previously 
re-vaccinated, while the vaccinations most successfully made did not protect 
from the most severe varioloid those older than ten years. 

M. Lombard stated, during a late discussion at the Belgian Academy of 
Medicine, that in the dreadful epidemic of variola which has just desolated 
Ijege, none of those who underwent re-vaccination took the disease. 
(Brit, and For. Med. Chir. Rev., Jan. 1851.) 

Steinbrenner, as the result of extensive investigation of the subject, says,. 
" re-vaccination is the indispensable complement of the first vaccination, not 
that it is always necessary, as some pretend who admit the loss of its pro- 
tective power by time, but because it is necessary in very many cases, and 
because there is no other means of distinguishing such urgent cases from 
those in which re-vaccination is unnecessary." (Traite sur la Vaccine,]). 
684.) He derives his arguments in favor of re-vaccination from its effects 
in the different European armies to which we have already alluded, as well 
as when performed by various individuals on a smaller scale, of whieh he 
presents a long array, and says that, in the absence of every other argument, 



372 APPENDIX. 

these results are strongly in its favor, because it is impossible that the pro- 
cess should be so often successful unless the success depended upon a 
predisposition which exposed the individuals to variola. He also demon- 
strates the necessity of general re-vaccination by considerations derived 
from the too great frequency of vaccinations which are not all protective, or 
only imperfectly so. 

M. Bousquet says, after giving a long list of instances of protection by 
re-vaccination without a failure, even in the midst of epidemics, a list 
which, he says, he could easily extend, " there has not been an epidemic 
which has not proved, at the same time, the virtues both of vaccination and 
of re-vaccination." (Nouveau Traite de la Vaccine — Paris, 1848, p. 506.) 
He also says (p. 501), " the success of re- vaccination is at the same time the 
effect and the proof of the wants of the system" — " when it succeeds, it not 
only proves that the protective power of vaccination is diminished, but it 
supplies a remedy for this diminution." 

The following are the conclusions on this subject of the Committee on 
Vaccination, of the French Academy, as contained in their report to that 
body, in February, 1845 : — 

1. Small pox rarely attacks those who have been vaccinated before the 
age of ten or twelve, from which age, until thirty or thirty-five, they are 
particularly liable to small pox. 

2. Re- vaccination is the only known method of distinguishing those 
vaccinated persons that remain protected, from those that do not. 

3. The success of re-vaccination is not a certain proof that the person in 
whom it succeeds was liable to contract small pox ; it merely establishes a 
tolerably strong presumption that he was more or less liable to take it. 

4. In ordinary periods, re-vaccination should be practised after fourteen 
years, but sooner during an epidemic. 

Among the conclusions of a report on the subject of vaccination, lately 
made by a Committee to the Belgian Academy of Medicine, are the 
following : — 

" As the immunity conferred by vaccination is not indefinitely absolute, 
re-vaccination, at least for a great number of individuals, is rationally 
indicated. 

" Experience has proved that a recent re-vaccination preserves from variola 
and varioloid, and that, practised on a sufficient scale, conjointly with vacci- 
nation, it constitutes a sure means of arresting the progress of this malady 
when it appears epidemically. 

" It succeeds best in proportion as it is most required, that is, the more 
remote the period since the individual has had variola, or has been vacci- 
nated. 

"During the prevalence of an epidemic of variola or varioloid, it is 
prudent to re-vaccinate all those whose first vaccination dates ten years- 
back, and all those whose first vaccination gives rise to any doubt." (Brit, 
and For. Med. Chir. Rev., Jan. 1851— from Gaz. Med.) 

Tommasini was led by his observations of its results during an epidemic 



APPENDIX. 373 

of variola in Italy, to recommend it to his fellow-countrymen, and we might 
add the names of many highly distinguished of our profession on both 
sides of the Atlantic, who concur fully in the importance of the practice, 
and some who even think it criminal to neglect it. 

We cannot but feel, therefore, in view of these facts, that the testimony 
in favor of re-vaccination is too strong to admit of its neglect. If no other 
argument could be adduced, the fact that it immediately arrests the course 
of epidemics when they appear, and that its faithful performance has almost 
entirely banished small pox from some armies in which it had formerly 
committed great ravages, would seem conclusive in its favor. 

It may perhaps be said that the results in the European armies to which 
we have referred speak against the manner in which primary vaccination 
was performed in these cases, and can hardly, with justice, be advanced in 
proof of what would have occurred, had the process been perfect in every 
respect. But allowing this to be true, they may still be adduced as a 
warning of the danger to \vhich our own population is at least partially 
exposed ; for it cannot but be true, that the process has been not unfre- 
quently performed among us in such a way as to diminish, if not entirely 
destroy, its protective power. Hence, we need re-vaccination as a test of 
security, and as the only one within our reach. And when we consider the 
almost perfect protection, thus far at least, afforded by re-vaccination, and 
how trifling is the operation, we can surely hardly entertain for a moment 
the idea of resorting to variolous inoculation, either as a test, or for addi- 
tional security against the failures of vaccination — an operation which is at 
least occasionally fatal, which subjects those on whom it is performed to 
some of the serious results which follow in the train of variola- itself, and 
which cannot be practised without multiplying centres of contagion, and 
thus aiding the ravages of the very enemy it is intended to combat. 

It is proper, however, to state, that the value of this practice is doubted 
by some, and even its propriety questioned. 

Occasional instances of an attack of varioloid after re-vaccination doubtless 
do occur ; but they are so rare as to be thought worthy of record when a 
single one occurs. Bousquet gives a case in an infant. M. Newnham also 
gives a case, after re-vaccination by himself. (Prov. Med. and Surg. Jour., 
May 1, 1850.) He considers the practice as a test of the efficacy of the 
first vaccination, and not a renewal of its influence, which, he contends, 
can never take place. The occurrence of a regular vaccine vesicle after 
re-vaccination he regards as a proof that the individual had not previously 
been successfully vaccinated. 

It is true, as our author remarks, that a talented commission, appointed 
for the purpose in Paris, reported against the practice of re-vaccination ; but 
it is equally true that another commission (the one whose conclusions we 
have quoted), appointed for the same purpose, at a later date, reported in 
its favor. 

As to the age at which its practice should be advised, that of about ten 
or twelve years is the one most generally recommended, advice founded on 



374 APPENDIX. 

the time at which cases of varioloid have been found to commence occur- 
ring — the proportion of cases under ten years of age being very small. 

Steinbrenner fixes upon the period of twelve to fifteen years of age 
as the one most proper for re-vaccination, and says that, if performed at 
that time, it will protect for life from variola. 

Bousquet says that there is danger of variola from the age of ten or 
twelve to thirty or thirty-five years, and that the time for re-vaccination 
commences from the age of ten or twelve years, that its value increases at 
fifteen years, and is never greater than between twenty and thirty. In 
times of epidemic prevalence, it should be practised earlier. 

In general terms, it may be said, that the prevalence of variola, the 
exposure of an individual at particular times, and anxiety felt on the subject 
at any time, may each afford a reason for performing an operation so trifling 
in its nature, and attended usually with so little inconvenience, that it had 
better be submitted to more than once unnecessarily, than neglected when 
it might have preserved from an attack of a loathsome disease, and perhaps 
even saved life itself. 

We need hardly add, that even greater care should be taken with the 
second and subsequent vaccinations than with the first, as we have not the 
same test of its success as in that case. It should therefore be a rule of 
practice to repeat the re-vaccination, if not successful the first time, and 
even to repeat it several times, in such a case ; as a failure to produce the 
disease might happen from some imperfection in the process, as sometimes 
occurs in the primary vaccination. 



EXPLANATION OF THE PLATES. 



PLATE I. 

The casual cow pox on the teats and udder of a black and white milch cow. 

The disease is at its acme ; and the skin being fair, a slight areola is visible 
around some of the vesicles, many of which have a bluish central tint. It exhibits 
papulae, vesicles with central crusts, unacuminated and acuminated vesicles ; 
imperfectly developed and also broken vesicles, both solitary and interfluent. 
The vesicles on the extremities of the teats are nearly of the color of the skin on 
which they are placed — a circumstance of itself sufficient to distinguish them from 
spurious or sub-epidermic vesicles. 

PLATE II. 

Casual vaccine vesicles on the thumb and finger of a boy who commenced 
milking on the 9th of October. On the 19th, he observed on his finger a red 
pimple of the size of a pin's head, and the next day, one on the thumb, very small. 
The engraving represents the vesicles as they appeared on the 23d, four days after 
the first was observed, and three days after the second. 

On the finger, the vesicle was small and flat, with a slightly depressed centre, 
containing a minute crust. On the thumb, the vesicle was also flat and broad, but 
visibly depressed towards the centre, where there appeared a transverse linear- 
shaped crust, corresponding, doubtless, with a fissure in the fold of the cuticle. 

PLATE III. 

Casual vaccine vesicles on the hand and thumb on the eighth day after the 
pimples were first observed (ninth day of papulation). 

On the side of the thumb was a flat vesicle, raised on a hard, red, tumid base. 
The vesicle was of a dirty white hue, with a slight central discoloration rather 
than depression, and a pale red areola extended around the vesicle, and beyond 
the last joint of the thumb. 



376 



EXPLANATION OF THE PLATES. 



On the back of the hand there was a smaller vesicle, of a different color and 
character, visibly raised, overlapping at the outer margin, and depressed in the 
centre, on a less circumscribed but obvious base. The vesicle was of a light flesh 
color ; its central crust dark brown ; and a moderate light rose-colored areola, 
and some tumefaction surrounded and raised the whole. 

PLATE IV. 



The same vesicles as in Plate III., on the following day (tenth day of papulation) 
— both vesicles considerably enlarged, and the areolae much increased. There 
was considerable tumefaction of the thumb and the back of the hand ; and the 
absorbent vessels, highly inflamed, could be traced by the eye into the axilla. 






WP 










troayjry 



PLATE III. 




trorty ff. !/ 



PLATE IV 




Zith.of Stnvny M Y 



INDEX 



Page 

Acclimatization, 82 

Affusion, cold, 189 

Adams, Dr., . . . 73,84,111,256 

Alexipharmics, 37 

Animal origin of Miasms, . 17, 181 

Al hasbet, 115 

Anthony, St., 204 

Ackworth School, . . . . 176,183 

Areola, 55 

Arnott, Mr., 219 

America invaded by Small Pox, . 43 
Scarlet Fever, 182 

Avicenna, 43, 116 

Archer, Dr., 240 

Angina Maligna, 161 

Baron, Dr., .... 17, 24, 41, 268 

Baillie, Dr., 137, 208 

Binns, Dr., 183 

Black Tongue, 358 

Blane, Sir Gilbert, 112 

Blankets, red, 94 

Bleeding in Small Pox, .... 98 

" Measles, 142 

" Scarlatina, .... 190 
" Erysipelas, . . . .229 

" Urticaria, 325 

Bousquet, M., 54, 256 

Bruce, Mr., 42 

Bryce, Mr., 261 

Bryce's Test, 254 

Bubo, pestilential, 59 

Burns, Mr., 117 

Calmiel, M., 209 

Ceely, Mr., . . . " . . . .17,266 

Cancrum oris, 131, 144 

Cicatrix, Vaccine, value of, . . . 249 

Chlorine gas, 84 

Chicken Pox, 292 

Cholera, Asiatic, 23 

Chomel, M., 209 

Colden, Cadwallader, .... 182 
Cline, Mr., 241 



Page 
Complication, secondary, ... 20 
Condamine, De la, ... 24, 47, 88 

Contagious origin, 25 

" of Erysipelas, . 213 

Contagion, 26 

Concurrence of Cow Pox and Small 

Pox, 251 

Cow Pox, Petechial, 12 

Constantine Africanus, . . . .115 

Confluent Small Pox, .... 59 

Superficial, .... 60 

Cotugno, 53, 67 

Creaser, Mr., 269 

Cullen, Dr., 148, 207 

Currie.Dr., 154,185,189 

Culmination of Epidemics, ... 84 

Debility, Exanthematic, .... 37 

" Scarlatinal, 167 

De la Garde, Mr., 132 

Delirium Ferox of Variola, . . . 61 

Desquamation of the Cuticle, . .165 

Diagnosis of Small Pox, . . 68,89 

" Measles, .... 134 

Scarlet Fever, . . .179 

Lichen, 69 

Diemerbroeck, . . . 29,32,44,116 

Dropsy, Scarlatinal, . . . 167, 198 

" pathology of, . . . • 355 

" treatment of, . . ' . . . 357 

Emetics in scarlatina, 188 

Enteritis, mucosa, 166 

Epiphora, 120 

Epidemic Mortality, 7 

Diffusion, 31 

" Influence, theory of, . . 32 

" Succession, 34 

Visitation, 84 

Tables of, 333 

Epizootic, Bovine, .... 181, 263 

Erysipelas, 106,203 

" of the scalp, .... 221 

" Gangrenosum, . . . 223 



378 



INDEX. 



Erysipelas (Ed em at odes, . 
" Phlegmonodes, 
" of the brain, . 
" Epidemic, . . 

Erysipelas, ages of deaths by, 



Pasre 
224 
224 
224 
358 
228 



Incubation of scarlet fever, . 
" of erysipelas, . . 

Inoculation, .... 28, 46 
" of erysipelas, 

" of measles, . . 



Page 
. 151 
. 217 
87, 108 
. 217 
. 138 



Erythema, 218, 329 

Nodosum, 331 

Exanthemata, character of, . . . 10 

" spontaneous origin of, 79 

enumeration of, . 4 

" state of blood in, . 19 

" co-existence of, . . 344 

Exauthematic Mortality, .... 5 

" amonsr blacks, ... 35 

tables of, . . . .333 

Fair, Mr., 29, 34, 71 

Fewster, Mr., 239 

Fever, characters of, 11 

" types of, 11 

" exanthematous, .... 12 
Fluidity, importance of, .... 63 
Fluids, variolous affection of, . . 62 

Fire, St. Anthony's, 203 

Fcetus in utero, Small Pox in, . 91,348 

Fomites, 30 

Friend, Dr., 40, 105 

Fothergill, 148 

Fothergill's Sore Throat, . 148,161 

Garotillo, 162 

Gibraltar, fever of, 33 

Garthshore, Dr., 223 

Glanders, 28 

Glossitis, 59 

Grease of horses, 268 

Gulliver, Dr., 260 

Haeem, 140 

Hamilton, Sir David, 309 

Dr., 194 

Haygarth, Dr., 31, 71 

Heat, febrile, 154 

Herpes, 302 

" Zoster, 303 

Holland, Dr., 32 

Hobson, Mr., case of, 158 

Home, Dr., 137 

Humoral pathology, 27 

Hunter, John, 54, 239 

Huxham, Dr., 148 

Hydrothorax, latent, 170 

Identity, exanthematic, . . . . 16 

Ignis sacer, 203,223 

Incubation, 12, 28 

" of small pox, .... 49 
" of measles, 117 



" influence on mortality, 353 

Jackson, Dr., 181 

Jenner, Dr., ... 48, 181, 238, 272 
John of Gaddesden, 94 

Katona, Dr., 138 

Lawrence, Mr., .' 233 

Layard, Dr., 17 

Leucophlegmasia, 200 

Lichen, 317 

" febrilis, 318 

" tropicus, . . . .-. . 323 

" syphiliticus, 322 

" vaccinus, . . . • 247, 321 

Louis XV., case of, 90 

Loy, Dr., 268 

Lues bovilla, . . . . 17, 181, 263 

Malignant Measles, 129 

Malignancy, acute, 76 

Mary, Queen, case of, .... 46 
Masks, use of, ...... . 107 

Mason, case of Mrs., 164 

Miasm, 2-6 

" ochletic 210 

Mead, Dr., .... 24, 88, 91, 105 
Measles, 68, 114 

" ages of deaths by, . . . 141 

Modified Variola, 60 

Cow Pox, ... .254 

Morbid poison, 26 

Miliaria, 308 

Montague, Lady M. W., . . 46, 48 

Mohl, Dr., 294 

Morbilli, 115 

Morton, 180 

Mucous membrane, affection of, . 18 

Navier, 18, 181 

Nettlerash, 324 

Nicase, St., 43, 204 

Non-naturals, 78 

Norwich Epidemic, 85 

Ochletic miasm, 210 

Opiates, 39 

Ophthalmia, rubeolous, .... 128 
" scarlatinal, .... 158 

" variolous, .... 64 

Pemphigus and Pompholyx, . .314 



INDEX. 



379 



Page 

Pemphigus, chronic form of, . .314 

" acute form of, . . . 315 

" gangrenosus, .... 315 

Peritonitis puerperarum, .... 210 

Petechial small pox, 62 

Peart, Dr. 196 

Pitcaim, Dr., 214 

Phlyctidium, 54 

Plenck, Dr., . . 199 

Pleurisy, variolous, 65 

Phrenitis erysipelatosa, .... 224 

Pneumonia, rubeolous, .... 126 

Points, vaccine, 261 

Procopius, 42 

Predisposition to small pox, ... 81 

" erysipelas, . . . 215 

Prognosis in small pox, .... 95 

Pyrexia, 11 

Quarantine, 30 

Raucedo, 120 

Recurrence of small pox, . . 88, 346 

" of measles, . . . - . 137 

" of scarlatina, . . . . 184 

Re-vaccination, .... 289, 370 

Rhazes, 43, 88, 115 

Rollo, Dr., 211 

Roseola, • 327 

" exanthematica, . . . .327 
Rose rash, ........ 328 

Rubeola, 114 

" sine catarrho, .... 121 
" maligna, 129 

Sacco, Dr., 268 

Sauvages, Dr., 208 

Sehwenke, Dr., Ill 

Secondary fever of small pox, . . 59 

" " measles, . . . 126 

" scarlatina, . . 184 

Scabs, vaccine, 261 

Small Pox, 41 

" miscarriage in, . . . 63 
diagnosis of, . . 68, 295 

" age of deaths by, . . 71 

" Hospital, founded, . . 47 

" to prevent pitting in, . 351 

Seasoning, ...... . . 81 

"Shingles, 303 

Sibbald, Sir Robert, . " . . . .147 

Scarlet fever, 146 

" ages of deaths by, . 177 

" affecting the foetus, . 185 

Seymour, Mr., case of, ... . 158 



page 

Sweating system, 44 

Stewart, Dr. L., 62 

Squibb, Mr., 164 

Susceptibility, exanthematic, . . 22 

Spcranza, Professor, 138 

Strophulus, 321 

Suspension, law of, 18 

Sydenham, . . 45, 101, 116, 144, 147 

Symmetry of disease, 16 

Statistics of small pox, . . 70, 277 

measles, . . . 133, 140 

" scarlet fever, . . . .174 

" erysipelas, .... 226 

Sutton, Robert, 47,110 

Surface, breach of, 216 

Syphilis, 69 

Surfeit, 318 

Thompson, Dr., 17,295 

Tongue, strawberry, 155 

Trophilus, saying of, 40 

Tweedie, Dr., 196 

Types of fever, n 

Urticaria, 324 

Vaccination, 237 

theory of, .... 262 
" mortality by small pox 

after, .' . . 285,365 

Van Swieten 56 

Varicella, 292 

Vicarious mortality, 6 

Vitus, St., 204 

Variola, 41 

" modificata, 56 

" confiuens, 56 

" petechialis, 62 

Variolae vaccinas, 263 

Velpeau, M 209 

Walker, Dr., 255 

Wachsel, Mr., 133 

Webster, Dr., 137 

Watkinson, Dr., m 

Williams, Dr., .... -13, 139, 226 

Ward, xMr., 176 

Wells, Dr., .... 192, 198, 207 

Willan, Dr., 41,114,217 

Withering, Dr., 116, 148 

Woodville, Dr, . . . . 23, 242, 270 

Zymosis, 29 

Zymotic diseases, 29 



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